Robert W. McLellarn the founder and director of The Anxiety and Panic Treatment Center, where he specializes in the treatment of anxiety disorders including Obsessive Compulsive Disorder, Panic Disorder, Agoraphobia and Social Anxiety
OCD is called the Doubting Disease for good reason, because doubt and uncertainty are, for the most part, the central theme in all kinds of OCD. While it is easy to understand this idea conceptually, it can be difficult to realize in the moment that the doubting issue has once again come up and has got you caught up in trying to eliminate the uncertainty. And it is when we get caught up in trying to eliminate uncertainty that we turn to compulsions and/or seek reassurance.
Let me give you an example. Let’s assume that we’re dealing with a client who has pedophilia OCD and worries that he/she indeed is at risk of sexually abusing a child. When this client worries that they could actually harm a child a natural response is to seek some sort of reassurance that they wouldn’t actually do this. So, this client might talk to a trusted friend, his his/her therapist, review their past history seeking evidence that they haven’t/wouldn’t do this type of thing, etc. And the search is on for finding way of feeling certain that they would never act on these thoughts. One of the devious things that OCD does, however, is make it difficult, if not impossible, to achieve this feeling state of complete certainty that one would never act on these thoughts. A compulsive cycle can get started when the client seeks certainty, is virtually always unable to get this feeling, and does more compulsions or seek more reassurance in a desperate attempt to feel certain and of course this also fails and the cycle continues until the client is exhausted and gives up the search. One of the ways this client might seek certainty is to use logic. Perhaps trying to reassure themselves that they wouldn’t act on these thoughts because they have never done so in the past. But when it comes to logic, OCD can always win because there’s always a possible exception. For example, even though this client has never in the past acted on these thoughts, how can he/she prove to him/herself (beyond a shadow of doubt) that they will not act on these thoughts in the future? If you think about it, this is an impossible task.
Clients can get caught for hours trying to analyze, figure out and somehow “prove” to themselves that they would never act on these thoughts, but virtually always these efforts are not successful and they are left at the end of the process with just as much doubt, if not more doubt, than they had when they first began and they are exhausted from the effort. Most people with this kind of OCD are understandably concerned that they could act on these thoughts. The idea of abandoning the search for certainty is rejected out of hand as completely unacceptable because it is seen as equivalent to literally taking the risk that it could be true. The idea of leaving any possible doubt that these thoughts could be true and might be acted on sometime in the future is completely unacceptable and so the client once again re-engages in the process of doing compulsions/reassurance to attempt to eliminate the doubt. Since this elimination of the doubt is never going to work the client keeps repeating a strategy that is doomed to fail.
Yet, if we understand the basic principles of exposure and response prevention (ERP – the gold standard treatment for OCD) accepting the uncertainty is precisely what must be done. Rather than seeking reassurance, using logic to prove they won’t act on the thoughts, analyzing or trying to figure out how to achieve a state of certainty that this could never happen, the treatment involves doing just the opposite. Actually allowing the thoughts to be there, acting as if they don’t mean anything, not trying to analyze or figure the thoughts out and not seeking any reassurance. Frequently clients with this kind of OCD will have developed patterns of avoiding anything that they fear might trigger their OCD such as headlines in the newspaper about a child molester who was just arrested, headlines about another Catholic priest who apparently had molested children in the past or any place where children might be, such as the children’s section of the library, toy stores, or playground areas in the park. An effective ERP program needs to address all of these areas. Examples of items in the exposure plan would be to not avoid these newspaper headlines but to actually seek them out and read them regularly. To, perhaps, read stories about actual child molesters. To go to places where children might congregate such as libraries, toy stores and parks. And while doing these exposures to allow whatever thoughts come up just to come up and not fight them or argue with them in any way. Some clients have even made audio recordings of the thoughts that troubled them and listened to this recording as they go to the library, toy store or park.
When clients are instructed to stop fighting, analyzing and seeking reassurance regarding these thoughts and start doing the types of exposure work mentioned above, it’s important that they expect to feel guilty because they aren’t actively pursuing certainty that the thoughts aren’t true. It will feel very wrong to go this route because it is seen as accepting the risk that something awful could happen and it would be their fault. It would be especially their fault because they did not do the responsible thing, i.e. figure out if the thoughts are true.
The issue of uncertainty cuts across all forms of OCD. And while OCD takes many shapes, there are four general types: checking, contamination, intrusive sexual or harming thoughts and just right OCD. When it comes to checking, the uncertainty issue is apparent when a client does something like checking the stove repeatedly before they leave for work in the morning to be sure that they haven’t left it on despite the fact that they have not used the stove in several days. Similarly, with contamination fears, uncertainty is an issue when despite having just washed their hands, the client fears that they have not washed their hands thoroughly enough and must rewash to be sure they are clean.
Life can get busy and complicated at times and often a gentle reminder can be helpful to focus on doing what makes sense to do. None of these tips is anything you haven’t heard before, but how many of these things do you do regularly? How do you think it might affect your life if you did more of these regularly?
Exercise regularly: There is good evidence that regular exercise helps manage both anxiety and depression, but how many of us actually exercise regularly? Too many of us rely on medications (either prescribed, over the counter or recreational) to cope with our anxiety.
Get enough sleep: Over the past several decades we are getting less and less sleep. There are many reasons for this change (television, social media, etc.) but whatever the cause, it is happening. We are just more resilient and better able to cope when we are rested.
Eat well: For too many of us when we don’t feel good, don’t exercise and don’t get enough sleep we also lose our motivation to eat well. Too much junk food, caffeine and alcohol only exacerbates our anxiety.
Integrity issues: If we aren’t living according to our values this will almost certainly cause us to feel off balance and lead to more anxiety.
Have fun: A good time with friends or even better, a good laugh, can go a long way toward helping life feel better and less anxious.
Being organized: Being at least somewhat organized can help us feel a bit more in control and a bit less anxious, though it’s possible to take this too far.
Good luck following with these suggestions and let me know how you do with what I’ve offered and please add to my list of you have a good idea.
OCD can be a difficult disorder to treat because it is full of tricks and unless you understand these tricks and learn how to play the game to win, then OCD has the upper hand. It’s almost as if the OCD has a tenth degree black belt in karate and you are just beginning. In this blog post I will list several of the more common tricks that OCD uses to “trick” people into doing their compulsions.
This isn’t OCD, this is real and you better take it seriously. The higher the stakes the more important it will feel to get this right. For example, a young mother who has postpartum OCD and is having harming thoughts about her new baby will be very reluctant to take the chance that her harming thoughts about her baby are harmless and can be ignored. Another example might be someone with contamination fears might worry that the yogurt has turned bad because it is one day past the expiration date and fears that if anyone was to eat this yogurt they would be poisoned and get sick or die. To not be “tricked” by these kinds of thoughts the person with OCD must recognize these thoughts as OCD thoughts and not take them seriously.
Though it is not always the case, in many instances people with OCD believe that urges are more significant than feelings which are, in turn, more significance than thoughts. While thoughts certainly can be experienced as dangerous, when a thought is accompanied by a feeling it is viewed as even more dangerous and the ultimate fear is a thought with the feeling followed by an urge. Using the same example in the paragraph above, a young mother with postpartum OCD has a thought about harming her child, and then to her dismay that appears to be followed by a feeling of wanting to hurt her child and then much to her horror she then has what she believes to be an urge to harm her child. Of course, all these thoughts, feelings and urges are all part of the OCD cycle but unless one understands this all three of these can be experienced as dangerous.
“The more you think, the deeper you think”. OCD often invites you to figure something out, analyze something and to dig deeper into the meaning behind something etc. And all of these are done with the false promise that if I can just get to the bottom of this then I’ll understand and it’ll be okay. In over 30 years of practice seeing OCD clients I have never once had a client “figure it out” in such a way that led to relief from their OCD. In fact, just the opposite is true. As the above quote suggests the more you try to analyze, figure something out, etc. the deeper you sink into the quicksand of OCD only to emerge on the other side of this process more frustrated and afraid than ever. OCD appears to offer the tantalizing possibility that if I can just figure this out this time then I’ll be okay, but it never works out that way.
Most people assume that we are innocent until proven guilty, but with OCD the opposite seems to be the case. For example, a person with OCD might worry that they did something inappropriate at a party last night after having had a drink or two. They will review their actions throughout the entire party and if there are some (understandable) gaps in their memory, they will assume that during those “gaps” they indeed did the inappropriate thing they were afraid of. It’s as if unless I can prove my innocence beyond a shadow of a doubt then I must be guilty.
When dealing with intrusive thought OCD – having harming thoughts towards a loved one or thoughts of doing something inappropriate sexually – one of the primary goals is to treat these kinds of thoughts just like any other kind of thought and not take them seriously (more about this kind of OCD in future blog posts). However, as the OCD person goes from being terrified by these thoughts to not taking them seriously they often encounter some bumps in the road. One of those bumps is the “trick”/belief that “If a thought doesn’t bother me then I must like and want that thought.” It’s easy to see how this would be very disturbing to the person with OCD and would reignite their anxiety. A closely related idea is that “Certain thoughts should scare/bother me or I’m not normal.” More about these types of beliefs in future blog posts.
I’ve written before about OCD tricks in an earlier blog post entitled “Some OCD Tricks and Distortions” dated February 27, 2014 and there are more “tricks” to come in future posts.
Let me introduce you to one of my clients that I will call Sally. Sally has had OCD for the better part of 30 years and her fears centered around “contamination” from her immediate family. When her compulsions first began over 30 years ago she recalls being concerned about being contaminated by germs. However, when asked why she still avoids touching her family members today she is unable to give a good reason other than she feels “uncomfortable”. I find that many of my OCD clients are so accustomed to doing their compulsions that it has become like a bad habit and they often are unable to give a good reason why they do the compulsion. The moment they feel an anxiety spike following being exposed to what they’re afraid of, they immediately launch into doing their compulsion without giving much thought to what they are doing and why they are doing it in the first place. It has just become the way they always do things. Some clients, like Sally, have even forgotten the original reason they started doing the compulsion in the first place.
Other clients may have a good idea of why they are doing the compulsion but don’t stop to evaluate if their “reason” for doing the compulsion is a valid one. Another client, Jim, also has contamination fears, but his “contamination” revolves around being exposed to psychedelic drugs. He will avoid wearing a jacket because somebody he met a few years ago who he thinks may have been around psychedelic drugs touched the jacket and thus the jacket is now “contaminated” with psychedelic drugs. Of course, when he stops to think about it, the actual risk of that jacket having drugs on them is virtually zero, but in the moment Jim chooses to avoid touching the jacket nonetheless.
In either of the above cases it seems appropriate for both Sally and Jim to have a way of being more aware of what they’re doing, notice how the OCD is tricking/seducing them into doing the compulsion, and how easily and quickly they resort the compulsion without really considering other options. To help clients become more aware (mindful) of what they are doing and why they are doing it, I have come up with the acronym SOBER, which stands for:
Stop, Observe, Be aware, Expand and Respond.
Stop What cues can you notice that OCD has entered the room?
Most clients can recognize when their OCD has popped up.
Take a moment to notice what’s happening. Observe What is going on?
What are you thinking?
What are you feeling?
Be aware Notice what your mind is telling you.
Be aware of what the OCD wants you to do.
Be aware of what “tricks” your OCD is using to get you to comply and do the
Expand Consider other options besides what your OCD is telling you.
Connect with what you value.
Connect with what you want your life to be about.
What choice will move your life in the direction you want it to go?
Where do you want your life to be in a month, 6 months, 5 years?
Respond Choose what you want to do.
What choice will move your life in the direction you want it to go?
Don’t just automatically react, make an informed thoughtful choice.
Using this type of process is, of course, much easier said than done and it will take much practice (and ultimately courage) to use it, but it at least provides a framework to slow down, consider options and make a deliberate choice. I think it was Victor Frankl who said (and I paraphrase) between the stimulus and response there is a gap and in that gap lies your freedom.
When it comes to dealing with an anxiety disorder, oftentimes our automatic response may be the wrong response. Let me explain. If you’re walking through the woods and see a grizzly bear on the trail in front of you, then your best response probably is to get away as quickly and as quietly as you can. Though in this case you would of course feel some anxiety, this wouldn’t be an anxiety disorder because the danger is real and her response was appropriate given the circumstances. However, if while driving you get anxious as you approach a bridge, and the bridge appears to be in good working condition, we would probably say that your response here is exaggerated and not in line with the actual amount of danger you would face when crossing the bridge. In this case we would probably say you have anxiety disorder this, your escaping the confrontation with the grizzly bear is appropriate, but your “escaping” your encounter with the bridge would be inappropriate. In addition, once this first bridge is avoided the first time it is highly likely that this bridge will also be avoided in the future and a “safer” bridge will be used instead. Since anxiety will often easily and quickly generalize, it is likely that this other “safer” bridge will soon elicit a similar response to the first bridge. And soon this second bridge is avoided and then the next “safe” bridge’s found in the process will repeat itself.
Just because you feel anxious doesn’t mean that you’re in danger. For example, when watching a scary movie in the theater many of us will experience real fear even know we are fully aware that we are not really in danger. Similarly, when we have an anxiety disorder we may feel anxious or afraid in the complete absence of real danger, or our anxiety/fear response is out of proportion to the actual degree of danger. Most of us make the assumption that if we feel anxiety/fear then there must be danger and respond accordingly by trying to avoid or escape whatever we perceive as being dangerous. When the danger is real, as with the grizzly bear above, our automatic response makes sense, but when the degree of danger is either not present at all, or is only minimally present, avoidance actually perpetuates the problem and over time makes the anxiety worse.
An acronym for the word FEAR that captures the essence of what I’m saying above and which many of my clients have found helpful is the following:
F – false
E – evidence
A – appearing
R – real
Robert W. McLellarn, PhD
Anxiety and Panic Treatment Center
Obsessive-compulsive disorder (OCD) comes in a variety of shapes and flavors, but there are primarily four main types. These four types are contamination OCD, checking OCD, “just right” OCD and intrusive thought OCD. Many people believe that OCD is primarily concerned with being organized and tidy, and while this certainly is one of the flavors of OCD, it is by no means the only or even the main type of OCD. In this post I will talk about the intrusive thought version of OCD and in subsequent posts I will talk about the other three varieties. Intrusive thought OCD is one of the less easily recognized versions and most people haven’t even heard of this kind. Even many professionals that I have met and worked with are not familiar with this kind of OCD. In intrusive thought OCD the sufferer is plagued with horrific thoughts involving doing something that is completely foreign to their value system. Whatever is most opposite to what they value and whatever is dearest to their heart this is what the OCD targets. The two primary versions of intrusive thought OCD are inappropriate sexual thoughts and harming thoughts.
The sexual thoughts can involve thoughts such as having sex with an inappropriate partner (such as mother, father, grandparent, sibling or child), having sex with animals, having sex with a cherished person (such as a minister or priest or Rabbi, or even figures such as Jesus), forcing sex on an unwilling partner, or almost any type of sexual act that could be considered inappropriate. The harming thoughts follow much the same pattern and usually involve thoughts of hurting or even killing a family member, loved one, stranger, etc. The person with OCD is typically horrified by these thoughts.
Once the person with OCD notices that he or she is having these kinds of thoughts, how they typically react to the thoughts actually perpetuates the problem. Understandably, a typical response would be to try to resist or get rid of these thoughts, which actually has the paradoxical effect of making the thoughts more “sticky” and harder to get rid of. What we resist tends to persist. So the more the thoughts are resisted the more they keep coming back and the stronger they get. The more these thoughts come back the more they are resisted and so the sufferer becomes even more convinced that there’s something terribly wrong with them because these thoughts won’t go away. Ultimately they fear they could lose control and act on their thoughts. The sufferer then might engage in a variety of rituals all designed to either prevent the thoughts from showing up or trying to neutralize the thoughts once they do show up, and neither of these strategies is effective at all and in fact they both lead, once again, to having more of these thoughts in the long run. This resistance to thoughts occurs because the sufferer is horrified by them and afraid of what these thoughts might mean about them. They may believe that because they have these thoughts that on some deep level they really want to do the acts they’re thinking about and that having these thoughts reveals their “true character” and that they really are at risk of acting on their thoughts. Of course, none of these beliefs are accurate, but once the sufferer is caught within the web of the OCD it is difficult to see a way out. It is somewhat like getting caught in quicksand: the more you struggle the deeper you go. Or as Sharon Davies has said “the more you think the deeper you sink.”
There are multiple ways in which this kind of OCD is insidious and devious. I have often used the metaphor with my clients of facing a martial arts expert with a 10th degree black belt who is extremely skilled and knows just how to penetrate my clients defenses. My clients search in vain for reassurance that these horrific thoughts do not mean what they fear they could mean and since they are unable to find this reassurance they become more and more anxious and may become quite depressed as well.
Most people try to think their way outs of these dilemmas and are quite distressed when they are unable to do so. I have never had a client successfully think their way out of these thought dilemmas. As with all kinds of OCD, Exposure with Response Prevention (ERP) is the best solution. However, I also think that, particularly with this kind of OCD, getting perspective on these thoughts is necessary. Being able to stand back from these thoughts and recognize them as OCD in addition to the ERP process is a good combination. However, standing back from these thoughts as I’m suggesting is no easy task. These thoughts create an anxiety spike which makes it feel like there is some real danger that demands immediate action of some sort. One of the tricks that OCD plays on suffers is the idea that because there’s anxiety spike there must be real danger. This is simply not the case. A useful metaphor might be of a fire alarm that keeps going off but there is no fire. At first when the fire alarm goes off it is responded to as if there is some true danger, but if the fire alarm keeps going off repeatedly and there is no fire eventually we learn to simply not pay attention to the fire alarm even though it is ringing very loudly. This, in a sense, is what I think suffers must do in response to the anxiety spikes. The spikes are experienced as very “loud” but there is no real fire and thus no response is required. Understandably it is extraordinarily difficult to not respond.
A typical obstacle to viewing these scary thoughts as a fire alarm when there is no fire, brings us to another aspect of OCD which is important to understand. Within OCD thoughts are assumed to be dangerous unless proven safe, which is the exact opposite of the way most people approach their thoughts. Without OCD, thoughts are assumed to be safe unless less proven dangerous. How can you possibly prove that these thoughts are safe and that you will not engage in the feared behaviors? How can you prove you will not do something? OCD demands you be sure something won’t happen, which is impossible Thus, OCD presents the sufferer with a challenge: prove that you will not do something in the future – Impossible! If one is to overcome intrusive thought OCD understanding the impossibility of this task is crucial. I will cover ERP for intrusive thought OCD in a future blog post.
Robert W. McLellarn, PhD Director Anxiety and Panic Treatment Center
I recently finished reading the book “The Mindfulness Workbook for OCD” by Jon Hershfield, MFT and Tom Corboy, MFT and I have to say I was quite impressed and have already started using many of their ideas with my current OCD clients (as well as clients with other kinds of anxiety disorders besides OCD!). Both authors clearly have a wealth of experience working with OCD and share a number of useful ideas, tips, and techniques in their book. Essentially, mindfulness is moment to moment nonjudgmental awareness of what is happening in your mind. When you start paying attention to what your mind is actually doing, it is really quite surprising how little of the time we really are present. So often we get lost in our thoughts, react to them without thinking, and get caught up in our thought streams which can take us into some very dark and scary places which are very far from the present moment. And this entire process takes place without us being aware that it is happening – we may not be aware that we have a choice to not pay attention to our thoughts and see then for what they are as just “thoughts” and simply not respond. As one develops the ability to be more mindful it is possible to notice these things happening and the very noticing then gives us the possibility of making a different choice. If, after touching a doorknob, I suddenly feel the urge to rush to the bathroom and wash the germs off my hands, I can mindfully be aware that I’m having thoughts about my hands being contaminated but also since I am now more aware I can make a choice to either do what I’ve always done, rush to wash my hands, or I can make a choice in the moment to stay with the discomfort and see what happens. Mindfulness allows me to be aware of the “automatic pilot” and to disengage from what may have become long-standing habits of responding to discomfort by seeking immediate relief.The authors also certainly incorporate more traditional Cognitive Behavioral Treatment approaches such as Exposure and Response Prevention and cognitive restructuring, but they add to our clinical repertoire these new techniques derived from mindfulness which I think only serve to enhance the effectiveness of these more traditional approaches.
The book begins with several chapters on mindfulness, followed by a very useful chapter entitled “Acceptance, Assessment, Action”, then there are nine chapters on applying their particular techniques to specific kinds of OCD, and finally a few chapters at the end on maintaining your progress and preventing relapse. I highly recommend this book to anybody who is suffering from any form of OCD, and, in fact, anyone suffering from other types of anxiety as well as I believe the mindfulness skills will be useful no matter what kind of anxiety someone is suffering from.
Many people struggle to find an appropriate therapist to treat their anxiety disorder, and so I thought I’d write this article and give some tips for how to go about finding a therapist with whom you can work. There are three areas to consider when choosing a therapist: 1) what qualities to look for regarding experience and/or training; 2) where/how you can find a therapist; and 3) once you have chosen the kind of therapist you want and know where to find one often times there are insurance issues to be considered as well. These three topics will be addressed in the paragraphs below.
When choosing a therapist it is almost always a good idea to seek somebody who has been licensed by your state – which usually means seeking help from a Psychiatrist, Psychologist, Licensed Clinical Social Worker, Psychiatric Nurse Practitioner or Licensed Professional Counselor. If you are seeking medication to treat your anxiety then your two choices from the above list are a Psychiatrist or Psychiatric Nurse Practitioner, but for the purposes of this article I’m going to assume that what you are seeking is a therapist to provide therapy for your anxiety and we will leave how to find a medication referral for a future article. Generally you will find that Psychologists have the most extensive training in providing the kind of therapy that you will want to seek out for your anxiety disorder, but there are, of course, exceptions to this and you may be able to find a very well-trained practitioner in the other professions listed. This brings me to the second criteria – experience. Though again there are exceptions to this rule, in general you want to seek out a therapist who has as much experience as possible treating the kind of anxiety are suffering from. The third criteria is whether or not the therapist you’re considering is a specialist not only in anxiety in general, but also specifically in the type of anxiety with which you struggle. Many therapists list multiple specialties such as depression, attention deficit disorder, marriage counseling, etc. and I think you are better off seeking somebody who specialize in treating only anxiety and doesn’t spread their efforts across multiple diagnoses. A fourth criteria is whether or not the therapist you are considering uses “evidence-based” therapy in their practice. What this means is that if a therapist uses evidence-based treatments then there is some research which supports their treatment techniques being effective. Rather than just relying upon their opinion about what works in therapy, they have consulted the research literature to find out what works best. The best researched therapy and most effective therapy for anxiety disorders is Cognitive Behavioral Therapy so be sure to ask your therapist if they provide this kind of treatment. Finally, in some ways the most important criteria is whether or not you feel comfortable with your selection. Many of the above criteria can be discerned from a website and don’t require any person-to-person contact. However, this criteria would involve at least a phone call and perhaps even a face-to-face meeting and could involve even the very first session of therapy. It’s important that the person you choose to work with is somebody that you feel confident about, trust, and whom you believe can be of help with your anxiety.
Now that you have some idea of the kind of therapist that you are seeking, the next question is how do you find someone who meets your criteria? This can at times be rather challenging. There are at least five different organizations each of which has a website with a therapist locator service that you can consult when trying to find a therapist. Here in Oregon, we have the Oregon psychological Association (www.opa.org) and there are at least four national organizations which may be of some assistance as well: The Anxiety and Depression Association of America (www.adaa.org); The Association for Behavioral and Cognitive Therapies (www.abct.org); The Academy of Cognitive Therapy (www.academyofct.org); and finally the Association for Behavioral Contextual Science (www.contextualscience.org). Other possible sources for therapists with whom you can work would be your primary care doctor, your insurance company, and finally you can ask among your family and friends for a therapist that they may have worked with themselves. Be cautious when using your insurance company as a referral source, because it is been my experience that the recommendations insurance companies make may not always be appropriate.
Finally, there are often insurance issues which will greatly influence which therapists you decide to work with. Just because you have insurance does not mean that your insurance will cover every therapist. Some therapists have chosen to join the panels of many insurance companies, some therapists choose to be on only a few panels, and some therapists choose to be on no panels whatsoever. Most insurance companies have a panel of providers and if you see somebody who’s on their panel you get reimbursed at a higher rate than if you see somebody who’s not on your insurance panel. Most insurance companies, though not all, also have called an “out of network” benefit. Which means that you can still see somebody who’s not officially on your insurance panel, but once again you’ll pay a higher rate for that person than you will for somebody who’s on your insurance panel. Being careful and thoughtful about this insurance issue can prevent you from getting a large bill which you didn’t expect. I recommend talking to both your insurance company and to the potential therapist so you know going in what your out-of-pocket costs are going to be.
Spending some time to select an appropriate therapist can help ensure that your therapy experience will be a good one. You want to choose a licensed therapist who is a specialist in and experienced with your kind of anxiety disorder. It’s also important that you feel comfortable with your therapist. There are a number of both local and national organizations which you can consult to try and find the names of appropriate therapists, you can talk to your primary care doctor, insurance company or ask family and friends. Finally, it’s important that you make sure before you start therapy that you know what your out-of-pocket costs are going to be.
Many of my clients with harm obsessive-compulsive disorder (HOCD) or pedophilia obsessive-compulsive disorder (POCB) have asked me “Why do I have all of these terrible thoughts? And why are these thoughts always about something awful happening to my loved ones?” Virtually all of my clients with these types of OCD interpret having these thoughts as possibly meaning that they want to do the things that they think about. They fear that having these thoughts mean that they want to harm their loved ones and/or engage in inappropriate sex. Until recently, I had at times struggled to give my clients a satisfactory answer to these questions. Luckily, I had a recent experience which gave me a way to answer my clients questions more satisfactorily.
Upon leaving my gym after a recent workout and as I was walking towards the parking structure with my car keys in my hand I suddenly had a clear mental image of dropping my car keys through a metal grate in front of me. As I approach the parking structure, and since I live in Oregon where it rains a lot, there is a large metal grate designed to capture and drain the water from any rainstorms. This grate is quite large and measures about 2 feet on each side. The grate is a series of metal bars each of which is about a half-inch wide separated by a space of about an inch or so and as I was walking towards this grate the thought suddenly occurred to me that if I wasn’t careful I could drop my keys through that grate and lose them forever. I had a distinct and clear visual image of holding the keys in my left hand, walking over the grate and then the keys slipping out of my hand through the grate into the pipes below. This brief episode has given me a way to explain to my clients why they have their “terrible” thoughts. Did my having that image of dropping my keys into the grate mean I “wanted” to drop my keys in the grate – of course not. Rather, I saw this image as a “warning sign” of what could happen if I wasn’t careful. So, in precisely the same way, my clients HOCD and POCD thoughts and images do not mean that they want to do these things, but rather, quite the opposite, they do NOT want these things to happen.
Another similar example that I’ve often used involves a grandfather walking his granddaughter to the park. Between the grandfather’s house and the park there is a rather busy street and so this grandfather always holds his granddaughter’s hand as they approach the street to be careful that she doesn’t dart out into traffic. If, under these conditions, the grandfather has the image of his granddaughter rushing out into traffic and being harmed does this mean he wants this to happen or is it, once again, another example of an image meant to warn him of what could happen if he isn’t careful. So just as in my example of the keys above, the thoughts and/or images this grandfather has are indications of what he does NOT want to happen rather than what he does want to happen. And just as my image of my keys falling into the grate lead me to hold onto my keys all the more tightly, in this case the image of his granddaughter being harmed leads this grandfather to be all the more careful with his granddaughter and hold her hand that much tighter.
I have found Obsessive Compulsive Disorder (OCD) to be very tricky and devious. Understanding and recognizing some of the tricks and distortions that OCD uses can be helpful when seeking to manage OCD. An OCD trick that one of my clients recently struggled with was wondering whether or not his current concern was OCD. This client was a phlebotomist at a local hospital and feared that he had inadvertently transferred blood to a roll of cotton which other phlebotomists would be using to dab future patients’ injection sites. He, of course, feared that the blood he had transferred might be infected and would cause the next patient to become ill and, in the worse case scenario, even die. He indicated that if he wassure that this concern was OCD he could use our previous work to stop doing his checking, stop seeking reassurance from his wife and family about what he had done and resist confessing his errors to his employer. He had become entangled in the web of seeking certainty around whether this was OCD. After much discussion we agreed that the best way out of his entanglement with this question was to accept the uncertainty and commit to stopping all of his compulsions. The minute he turns back to seeking certainty about whether or not this is OCD he has once again become entangled in the OCD web. Seeking to find “the answer” “to know for sure” or anything like that just further deepens the entanglement with the OCD web and will never result in any type of lasting solution. He must surrender the need for certainty if he wishes to free himself from the OCD.
A second OCD trick that had hooked this client was the idea that if I’m a little bit responsible then I am totally responsible. This has also been called black and white or all or nothing thinking. He could see that there were other people involved in the process, such as other phlebotomists, etc., but nonethelesssince he had some responsibility, he felt totally responsible for the potential (disastrous) outcome. Our way around this dilemma was to draw a “responsibility pie”, list all the people who could be potentially responsible for the outcome he feared and then beginning at the top of the list assign slices of the pie based upon how responsible each person was and ending the list with the client himself. What he discovered was that by the time he had divided the pie into sections based upon how responsible others were, hisslice that remained was very tiny indeed.
A third OCD trick that one of my current clients has fallen prey to is “if it doesn’t feel right then it must not be right.” This is usually referred to as emotional reasoning. Just because something doesn’t “feel” right doesn’t mean that there’s anything wrong. In fact, within the OCD world many things feel wrong and/or dangerous when they are not. In a very real sense when you have OCD you cannot trust your feelings in those portions of your life where the OCD has become active. Just because you “feel” that your hands are still dirty and does not mean that that is true. So in coming to manage OCD it is important to notice these feelings and then mindfully pause before responding to them. Rather than simply react and do what feels necessary, to pause, to reflect and then to choose the response that makes the most sense. For many clients it is rather disconcerting to consider the idea that they really cannot trust their feelings when it comes to the OCD. A particularly troublesome example of this is when the client suffers from Scrupulosity OCD. Many scrupulous clients make the assumption that these “feelings” are actually a message from God and/or the Holy Spirit and thus must be listened to and obeyed.
A fourth, and final trick for this blog post, is the idea that because a thought issomehow “louder” or “brighter” in one’s mind that therefore it must be more significant and worthy of attention that other thoughts. The idea here is that just because a thought is brighter and louder it means more, which of course isn’t true at all. It’s as if we are saying that when driving down the street the brightest neon sign is the most important neon sign or that the person who isspeaking the loudest must be saying the most important things. As with all forms of OCD, the way to not be taken in by this trick is to first and foremost be mindfully aware of what your mind is telling you. To look “at” these thoughts rather than “from” these thoughts. To notice that your mind is telling you the brightest and loudest thoughts are somehow different from the rest of your thoughts which of course they are not. To then mindfully resist the urge to treat these thoughts in some different way and put them into your usual thought stream and treat them like you would any other thoughts