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By Molly Schiffer, LGPC

One of the things I find most heartbreaking about working with some of my OCD clients is that the disorder has ripped from them that which they treasure most and in turn engendered the very life they fear. In other words, it makes you become what you fear, just not in the way you’d expect. Those with Harm OCD may fear being rejected after hurting someone, but then they isolate themselves from their families. Those with Pedophile OCD may give up being a parent so there is no chance they will molest their child, but then they live a life not feeling safe around children.  Those with Health Anxiety OCD may worry that unidentified or untreated illness will rob them of a fulfilling life, but then they miss out on enjoying the life they always dreamed about having by devoting all their attention to trying to be sure they are not ill. Regardless of the form OCD takes, OCD is the dictator who declares the lengths that must be followed to obtain 100 percent certainty and just as you begin to think you’ve appeased him… the dictator changes the rules.

Understanding Health Anxiety OCD

Regardless of whether we call it Health Anxiety OCD, Hypochondriasis, Illness Anxiety Disorder or Somatic Symptom Disorder, this content area is often misunderstood both in the medical profession and the mental health field. Some of the confusion arises from failing to understand that the diagnosis refers to a person that is chronically anxious about their health, not about whether they are actually sick or not.  The fact is, one can be sick and have Health Anxiety OCD.

As with all content areas of OCD the real problem is not the content of the obsession, but the process of how you relate to and respond to it.  Specifically, the problem is believing that you have to do compulsions in the effort to obtain certainty your fear is untrue.  These failed efforts to be certain about one’s health ultimately lead to feeling less certain and more afraid. This being said, the content of all OCD sufferers’ obsessive thoughts always feels and seems important, and this sense of urgency about it distracts from recognizing the process problem.  Living with Health Anxiety OCD can feel like you are living on borrowed time, which makes it nearly impossible to enjoy anything. Instead you feel driven to escape what could be a potential death sentence or avert some other tragic misfortune.  What’s worse, it feels like you alone are responsible for carrying out this mission.

I remember as a child asking my mom what she was always so afraid of, and she said that she was afraid that she would be sick, and that it would be her fault for not being vigilant about watching for signs and symptoms. The look on her face was one of terror and bewilderment as she told me how unbearable it would be to find out she’s sick and to know that it would be all her fault for not having caught it sooner. As a child this made no sense to me but now, as an adult who has lived with OCD (and now specializes in the treatment of OCD) I understand that the terror and fear she felt was real. Her “fight or flight” system had signaled an emergency which she did not know was a false alarm. My mother was afraid of being sick, and everything that comes with being sick, but what really tormented her was the thought that she would be responsible for getting sick due to her failure to have checked enough.

Feared Consequences in Health Anxiety OCD

Feared consequences typically associated with Health Anxiety OCD include fear of dying or suffering from an illness of course, but also fear of permanent suffering, both mentally and physically, fear of abandoning your family because you didn’t take care of yourself, fear of never getting an accurate diagnosis and never finding treatment for your symptoms (real or imagined). This often includes intense pressure not only to figure out what is wrong with you, but also to be sure you are receiving the “right” treatment, for which you also take full responsibility. It is important to recognize when hyper-responsibility is playing a role in your health anxiety, so it can be targeted effectively during treatment.

What Health Anxiety OCD Makes You Feel Responsible For

Here are some ways OCD uses the fear of being irresponsible to keep you stuck in health anxiety.

Responsibility for seeking a diagnosis

  • What if I am ill but no one can figure it out because there isn’t a name for it?
  • What if this doctor read the results of the tests wrong?
  • How do I know that I am not developing an illness that has not been detected?
  • What if my failure to find an answer leads to endless suffering due to my awareness of symptoms

Responsibility for being vigilant about monitoring symptoms

  • What if this sensation or symptom is a sign of cancer or a chronic illness?
  • If I don’t check for signs of illness it could end up being my fault for not checking.

Responsibility for avoiding the potential of contracting an illness

  • What if I should not have allowed myself to be around someone who appeared ill?
  • What if I have not paid close enough attention to something that could have gotten me ill?

Responsibility for inadvertently causing harm

  • What if I have an undetected illness and get someone else sick?
  • What if I am currently sick or get sick due to my own lack of vigilance?

Responsibility for reporting symptoms and sensations

  • What if I fail to describe my symptoms accurately which results in the wrong diagnosis?
  • What if I fail to recognize changes in my symptoms?
Common Compulsions in Health Anxiety OCD

It can be easy to miss when apparent efforts to responsibly take care of your health are actually compulsions that fuel your obsessive thinking.  Here are some things to look out for:

  • Asking friends or family to examine you for signs of illness
  • Repeated visits to multiple doctors
  • Requests for unnecessary (and/or repeated) tests
  • Excessively checking your own body to look for new symptoms or changes in symptoms
  • Reassurance seeking from multiple sources (professional and non- professional)
  • Self-reassurance by reviewing behavior to make sure the right precautions were taken or repeating comforting advice already given
  • Excessive visits to the Emergency Room
  • Avoiding places where one might be exposed to germs or sick people (malls, doctor’s offices, grocery stores, etc.)
  • Avoiding objects imagined to cause illness (standing in front of the microwave, holding phone to one’s ear, anything sharp, anything with certain chemicals, etc.)
  • Neutralizing bad “sick thoughts” with good “healthy thoughts
The Google Problem

When I was a kid (yes, back then we used encyclopedias) whenever someone was anxious about a potential health concern we went to the bookshelf and consulted a very large medical book. While looking for reassurance from a medical book was still a compulsion which resulted in finding new possibilities and new questions, there was a limit to what information you would find.  Plus, it took a fair amount of effort.

Today we have Google, a limitless source of information which can all be obtained with a click. For those with Health Anxiety OCD, google is often a source of great misery and suffering. It starts with OCD selling you the lie that you could have your answer if you just looked up this one thing and then you could put it aside and carry on with the rest of your day (wouldn’t that be glorious?). However, it never works out this way because with Health Anxiety OCD googling itself is a reassurance seeking compulsion which maintains the cycle of OCD.  It does this by reinforcing the idea to your brain that not only is your health in question but that you better do something about it fast.

This is partly what makes Google so problematic because it offers health anxiety sufferers a promise of immediate answers and it never says “No, you have had enough, stop googling”. It feeds you possibility after possibility, mostly negative, which serves to keep you terrified, desperate and even more convinced than before that you are probably very ill. Unlike other addictions where there is an opportunity to pause prior to running out to make a purchase, Google is immediately and readily available at your fingertips. Googling is a common compulsion in many forms of OCD and is usually one of the first compulsions I work with my clients to reduce.

Case Examples

Debbie is a 27-year-old female who initially presented to her doctor with vaginal burning and was concerned she might have an infection! Debbie’s pap smear came back normal and she tested negative for any urinary tract bacterial infections. Debbie went home and was fine until she began to feel what seemed like the same sensation of burning she had 2 weeks prior. Debbie became fearful that maybe now she had an infection. Debbie returned to the doctor who again stated that Debbie did not have an infection and maybe she needed to drink more water. This went on for many months. Debbie began to go to different doctors due to feeling embarrassed about going back to the same doctor a second or third time. Debbie was constantly aware of the sensation of burning that seemed to get worse day by day. Debbie was plagued by the following thoughts: What if I have these symptoms forever? What if there is something wrong and nobody can figure it out? What if I have an STD that has been dormant for all these years?  Debbie started to Google STD’s and began to worry that maybe she had undiagnosed HPV which could result in cervical cancer. Debbie began to wonder whether she had used protection with every sexual encounter.  She began to Google information about how to know if you have HPV which only led her to more questions. She also examined herself daily to look for irritation or signs of an infection. Debbie knew she had OCD but this time her OCD had her focused on the (real) sensations that might indicate an illness instead of the familiar intolerance of uncertainty and discomfort.

Mark is a 52-year-old male who is preoccupied with several moles on his body. Mark has a family history of skin cancer. Mark was diligent with checking the moles on his body to make sure there weren’t any changes in shapes or sizes that could be a sign of melanoma. Every day after showering he would look over the moles before getting dressed. One day he had the thought “how will I know that it didn’t change, and I just didn’t notice” and “what if I have melanoma and it is my fault for not doing a better job of monitoring my body?” The more Mark looked at the moles the more confused he became and wondered what should a mole look like? Mark innocently looked on the internet searching “what does a healthy mole look like”? Mark was immediately bombarded with images of healthy and unhealthy moles. Mark began to frequent the doctor’s office and his dermatologist’s. Both doctors said Mark was fine, but as soon as he left the office he would be plagued by the thought “maybe he didn’t see the one I was talking about.” Mark stared at the moles to look for inconsistencies in shape and color and frequently asked his wife to examine his moles. He began to remember all those summer days in his teens where he had chosen not to wear sunscreen despite his mother’s warnings. Mark’s OCD had him focused on the belief that he was being responsible to monitor changes in his skin when in fact he was on a never-ending quest for certainty driven by an over-inflated sense of responsibility.

Inaccurate Beliefs Driving Health Anxiety

In treating any form of OCD, it is important to identify unhelpful ways of framing experiences that drive your belief system and perpetuate you engaging in compulsions. To assist with this process, I often like to talk about fun house mirrors and ask my clients what their experiences have been when looking at their reflection. Most of the time they respond by saying they looked fat and short or tall and skinny. I then discuss how if they believed what they saw, they may feel driven to start exercising, to drink daily milkshakes or maybe even to look for work in the circus. I use this to illustrate how mistaken beliefs (or cognitive distortions) drive OCD sufferers to engage in compulsions, leading to more uncertainty and misery.

Mistaken Belief: You can know the status of your health with absolute certainty: You can never know with 100 percent certainty that you are healthy. Chances are, if you suffer from health anxiety, you know the anguish of going to the doctor’s and immediately upon leaving the office thinking, “What if I didn’t explain my symptoms accurately? What if they misunderstood what I was saying? What if they missed something important?” The truth is that with being human we all run the risk of getting sick or having an illness pop up with no warning. I hate to say it, but we will all die and that may be the result of illness or of old age, but either way our choice is to enjoy our life being present for the things that matter or spend all our time trying to prevent illness and miss out on all the joy that can be found living in the moment.

Mistaken Belief: Symptoms and sensations indicate illness and always have a specific cause that can be determined:  This is a fallacy. Sensations happen all the time for many reasons, including for no specific reason. Sometimes sensations and symptoms are related to a specific health concern, sometimes they are indicators of nothing. However, once they are noticed, focused on and resisted, they tend to become more prominent simply because of the hyper-focus on them. To convey this idea with my clients I sometimes like to ask them where they are itchy. At first, they look at me blankly, but then usually identify a place that is itchy. The idea being that when you scan your body for sensations and symptoms you will likely find them. Just because you are aware of these experiences does not mean they are necessarily important or dangerous.

Mistaken Belief: Having the perfect diagnosis will always lead to effective treatment and elimination of all symptoms: While often there are effective treatments for your symptoms, this is not always the case. There are some conditions that even when diagnosed treatment options are limited. This is especially true for some chronic conditions such as Inflammatory Bowel Disease, Headache Disorders and Musculoskeletal conditions like Fibromyalgia. Your OCD is misleading you to believe that having a diagnosis (i.e. “the Answer”) will lead to relief.

Mistaken Belief: You are responsible for taking all possible precautions to avoid illness. The reality is that if you took every precaution you could possibly take to prevent illness, you would never be able to leave your home or have anyone come to your home, including the mail carrier. Even then, you couldn’t be sure that you took all precautions to prevent illness. Most enjoyable things in life inherently come with some risk.  If you get out of bed, your risk goes up.  Stay in bed too long, and your risk goes up too.  But your OCD, not restricted by reason, would have you believe that there is no amount of risk worth taking when it comes to your health.

Mindfulness and ERP for Health Anxiety OCD

Exposure and Response Prevention (ERP), simply put, is a process where you confront your fears about your health and refrain from doing compulsions. People often think of mindfulness and ERP as two separate strategies when in fact mindfulness is often a part of ERP. While doing exposure to your fear you are mindfully allowing yourself to both approach and remain in the presence of your fear and mindfully choosing not to engage in compulsions. The purpose of this exercise is to essentially retrain your brain to respond to the obsessive thoughts without doing compulsions which ultimately teaches your brain that these thoughts are irrelevant (or tolerable) and require no response.

Learning to respond differently to these thoughts ultimately results in accepting uncertainty about their meaning. This both reduces your anxiety about the thoughts and increases your willingness to feel whatever anxiety may remain.

Examples of Exposures for Health Anxiety OCD
  • Reading articles about people dying from diseases both common and uncommon
  • Watching movies or videos about someone with a terminal illness
  • Visiting hospitals, nursing homes, or places where you might fear acquiring an illness
  • Writing imaginal scripts about being chronically or terminally ill and the consequences that could arise from this
  • Writing imaginal scripts about failing to do enough to prevent an illness, failing to take enough precautions or perfectly follow medical advice

For any of the above approaches to work, they must be paired with resisting checking, comparing, reassurance-seeking or other compulsions.  Making contracts/agreements with loved ones to help you resist reassurance-seeking can also be instrumental in your progress.

Mindful Awareness

With health anxiety, practicing mindful awareness is knowing that you tend to be aware of your body’s symptoms and sensations in every possible way and understanding that simply being aware doesn’t necessarily have to be experienced as aversive. The awareness is experienced as aversive often because of the meaning and judgement subscribed to the experience. Being mindful of physical symptoms and sensations means viewing them from a different standpoint.

I don’t know about you, but I never wake up being greeted by a host of positive thoughts about my day that inspire me to feel good. Instead my brain presents potential pitfalls and disastrous outcomes that if I spend much time thinking about will land me right back into bed. With mindful awareness I can just expect to have these thoughts when I wake up, and instead of trying to make them disappear I make a choice to note them as they arise and just allow myself to get up and move forward. Accepting the presence of unwanted thoughts does not mean accepting the content of the thought as being true.

For example, I just had the thought …what if I am brewing some kind of cancer at this very moment and am irresponsibly just sitting here doing nothing about it? I could respond by taking the thought as a message or warning of some kind and immediately contact my doctor or I can thank my brain for its creativity and continue to do what I value, which at this moment is to continue to treat and support those with OCD.

Standing Up for Yourself

Sometimes living with Health Anxiety OCD can feel like you are living in your own private hell that never seems to end. On top of the despair you may feel, your OCD condemns and berates you for all the ways you imagine you may have failed, which then leads you to feel more isolated and often depressed.   From this standpoint it is difficult to feel motivated or even capable of doing what it requires to get better. This is where self-compassion can be especially helpful. At this point my clients frequently scowl because they assume I am referring to some kind of “give yourself a break type statement” which they often hate. However, self-compassion is simply about viewing yourself as a human being who has challenges like all other human beings. Self-compassion is a way of separating yourself from the nasty voice of OCD and allowing yourself to be honest about the situation without judgement and criticism. From this position you are better equipped to challenge your OCD and actively engage in treatment.

The good news is you are not alone. Currently you may only know the suffering associated with your health anxiety but through the right treatment, there is hope of learning to appreciate the way your mind works. You may even learn to laugh at the ridiculousness of some of the ideas your OCD has you focused on and you may begin to appreciate the creativity it affords you.  Above all, you may get to truly enjoy the benefits of the good health your OCD is so protective of.

Molly Schiffer, LGPC is a psychotherapist specializing in OCD and related disorders at The OCD and Anxiety Center of Greater Baltimore.

The post Shedding Light on Health Anxiety OCD appeared first on The OCD and Anxiety Center of Greater Baltimore - Director, Jon Hershfield, MFT.

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It can be argued that many forms of OCD come down to a fear that lack of vigilance could lead to a loss of identity. One with Harm OCD may worry that failure to catch that one impulse could lead to spontaneous discovery that he/she is a violent or harmful person. One with sexual orientation obsessions may be excessively concerned that this one thought or sensation left up to uncertainty could reveal the discovery of gay denial. Choosing to take the risk of accepting you might have touched your shoe but just aren’t going to pull out the hand sanitizer this time could be the slip that reveals you to be an irresponsible or unhygienic person. Nowhere is this identity over-protection clearer than in the case of moral scrupulosity.

In this blog series, I’ll be exploring the form of OCD that manifests most specifically as excessive concern about right and wrong and the false dichotomy of the good person/bad person in OCD. This first entry in the series will focus on defining and recognizing moral scrupulosity in OCD.  It’s important to understand that what I am calling “Moral Scrupulosity OCD” here is not a different kind of disorder, just a name to describe a manifestation of OCD for the sake of simplicity. The term “scrupulosity” is often used to describe religious obsessions, which typically manifest as getting too caught up in the details of one’s religious tenets and whether or not they are being perfectly followed. Moral scrupulosity is, thus, obsessive concern with whether or not one is being good or bad, independently from religious expectations. In other words, the concern is with the “quality” of one’s humanity in the context of the culture in which he or she lives. The values and ethics of that culture are the rules that OCD dictates must be followed perfectly. More to the point, this perfection must be constantly proven beyond the shadow of all doubt. Even as I write this, I can sense the itch of my own morality nuisance demanding that I truly capture the suffering of those with moral scrupulosity OCD. I won’t.

Common manifestations of Moral Scrupulosity OCD

Here are some common manifestations of moral scrupulosity I have seen in clinical practice:

  • Excessive concern with being 100% honest
  • Excessive concern with the idea of being “good” or of not being “bad” (a so-called “good” person wouldn’t think or do xyz)
  • Excessive concern with getting in trouble or breaking rules
  • Excessive concern that a past act was immoral
    • may include awareness of an actual moral misstep but with obsessive need to know exactly how much
    • may include concern that others would reject you if they knew about it
    • may include concern that a thought about an immoral act could be a memory of an immoral act that likely did not even occur (see my blog on False Memory OCD)
  • Excessive concern that adultery or some disloyal act could have or did possibly take place
  • Excessive concern that one has caused someone else to be immoral

Moral scrupulosity likes to borrow from other common OCD manifestations. Though the YBOCS has it listed under the subcategory of religious obsessions, moral scrupulosity actually creeps in to nearly every kind of OCD. Here are some examples:

  • Contamination
    • It would be morally wrong to touch this with dirty hands
  • Checking
    • It would be morally wrong to risk the door being unlocked, the stove being on, etc.
  • Harm
    • It would be morally wrong to be careless in a way that could lead to harm
  • Sexual orientation obsessions
    • It would be morally wrong to deceive others about my attractions and let them continue to believe I am of one orientation when I could be another
  • Pedophilia-related obsessions
    • It would be morally long to have any intrusive thought about a child
  • Relationship obsessions
    • It would be morally wrong to let my partner stay in a relationship with someone who has my thoughts
  • Religious scrupulosity
    • It would be morally wrong to be philosophically flexible or choose my own interpretation of religious doctrine on moral issues
Compulsions in Moral Scrupulosity OCD

Compulsions, that is, behaviors that OCD sufferers engage in to feel more certain that their fears are untrue, can also cover a wide spectrum of human behavior in moral scrupulosity. Consider that for each individual, what makes them believe themselves to be moral is mediated by their own personal worldview. Often I find that people are engaging in compulsions that look like they serve one function, but really serve another, and this problem of failing to recognize why a compulsion is being done can get in the way of treat the OCD. For example, it’s easy to assume that a person who excessively washes their hands is afraid of being sick. But they may be more concerned with getting others sick. Or, getting themselves or others sick may not even enter into it. They could be simply measuring their moral integrity against the certainty that they are being hygienic. In this case, exposure to the fear of getting or causing illness will be less effective than exposure to the fear of possibly being socially deviant or inadequate.

Here are some common compulsions related to moral scrupulosity:

  • Common compulsions
    • Reassurance seeking about moral issues
    • Confessing perceived immoral acts or thoughts
    • Mentally reviewing/checking for acts to determine moral integrity
    • Mental rituals
      • repeating neutralizing “good” thoughts
      • ruminating on hypothetical moral scenarios to test responses
      • repeatedly rationalizing why a past act was not immoral in context
    • Avoidance of morally ambiguous situations
    • Self-punishment to prove moral concern
    • Excessive apologizing for perceived/potential moral failures
    • Washing and checking behaviors connected to moral concerns
    • Excessive donating or other acts of exaggerated altruism/generosity

At the core of any obsession is the misguided demand for certainty. Certainty seeking in some areas may, at least, appear more fruitful than in others. For example, you could compulsively check to make sure you’ve turned off the stove. You will see that it is off and that will produce in you a sense that it has been turned off. It’s unlikely to last, of course, but that’s the subject for another blog. But how do you check your morality to make sure it is on or off? You could assign a list of moral guidelines to follow that are consistent with your cultural context, and you can even convince yourself that confidence in this list (as opposed to some other list) is warranted. But at some point you are still going to have to decide whether or not you trust your own judgment, your own memory, and your own self-talk. Though everyone is entitled to a reality check now and then (as in, “come on, it’s not that big a deal), repeatedly reassuring oneself to get certainty always ends up colliding with the wall of reality, that something may be getting missed.

ERP and Moral Scrupulosity OCD

Exposure and response prevention (ERP) is the most effective way to treat any kind of OCD. But you may be concerned that exposure to moral concerns means doing immoral things or may have consequences that are not immediately revealed. In other words, if you have a fear of lying, you may think the best way to do exposure is to lie, but this is not necessarily the case. The exposure to the fear of lying is to engage in behaviors where it is unclear whether a lie has taken place (or the significance of the bent truth is unknown).

Or you may have a fear that you have behaved in an immoral way and that there may be negative consequences that won’t be known for years or decades (e.g. your or someone else’s life is ruined later). This confusion is why it is so important to remember that the battle with OCD is a battle of uncertainty tolerance. The fear to confront over long term damage is the fear that you cannot tolerate sitting with the uncertainty now and for the unknown future.

The Goals of ERP

The goal of ERP is never to prove that you’re a good person. That’s a trap. Any goal that by definition is impossible is obviously no goal worth pursuing. Here are the actual goals of treating your moral scrupulosity with ERP:

  • Improve uncertainty tolerance
  • Violate the expectation that uncertainty about morality is intolerable
  • Improve ability to commit to value-based behaviors despite unwanted thoughts/feelings
Will my therapist make me do terrible things?

ERP therapists make a lot of jokes about doing terrible things, but the truth is we are as invested in preserving your morality as you are. We just don’t believe in certainty. We always work within the client’s moral framework and without the intention to violate it. This requires a fair amount of collaboration so that both the therapist and the client have enough trust between them to take the risk of getting mastery over OCD. First, we need to identify what lines will not be crossed. This is as true in moral scrupulosity as it may be obvious to those with religious scrupulosity. We wouldn’t ask a religious person to knowingly sin and we wouldn’t ask a morally scrupulous person to take money out of a homeless person’s cup – not because we’re especially good people, but because it just doesn’t work. Head on confrontation with uncertainty is what works. So once we’ve identified the lines not to be crossed, we want to explore the area near the line and learn to walk around it more casually, without compulsions, and take ownership of the fact that a gust of wind may accidentally push us over it.

In addition to doing exposures to real life experiences, which often boil down to behaving in ways that are consistent with those around you but without checking and reassurance-seeking about whether you have done so in the most moral way, imaginal exposures can be very useful. Writing scripts articulating that uncertainty will be accepted about morality, that immoral acts could bring about unwanted consequences, or that the scripts themselves are immoral acts can all be effective.

Well, that’s good enough for now…

For now, consider this – OCD is driven by compulsions, behaviors you engage in to make yourself feel certain that you, in this case, are moral. To get you to do compulsions OCD has to cut you down. It has to inundate you with mental spam mail about your perceived moral failings. Learning to live joyfully with uncertainty, even about your inherent “goodness” as a human being is the best strategy for beating OCD and feeling good about yourself. OCD uses the fraudulent concept of “bad person” to con you into trying to prove you are otherwise. I was once asked why OCD never tries to convince you that you are a good person. The answer is that this does not need convincing.

In the next installments of this series I will take a look at some case examples of moral scrupulosity in OCD and how cognitive approaches, self-compassion, and the role of mindfulness can be used in treatment. All of these can be used to enhance your ERP work and liberate you from the irrational fear of being unlovable.

Jon Hershfield, MFT is a psychotherapist in private practice and director of The OCD and Anxiety Center of Greater Baltimore.  Follow him on Twitter and Facebook

The post Moral Scrupulosity OCD: Part One appeared first on The OCD and Anxiety Center of Greater Baltimore - Director, Jon Hershfield, MFT.

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Your whole life you were one way and now you appear to be another. This statement represents one of OCD’s cruelest, and frankly, laziest efforts to dominate your attention. Once it gets you to sign the contract, that you will commit to being unhappy so long as you are this way now and not the other way as before, you remain its slave. Hyperawareness or sensorimotor obsessions are characterized by an excessive concern that your attention to some otherwise forgettable or involuntary bodily process will become totally and permanently conscious. In other words, we do a lot without thinking about it, so thinking about it feels uncomfortable. Here are some examples of common experiences people with hyperawareness obsessions struggle with:

  • Blinking
  • Swallowing
  • Breathing
  • Heartbeat
  • Hunger levels
  • Bladder or bowel pressure
  • Itches or minor pains
  • Hair touching forehead, ears or neck
  • Positioning of body parts (i.e. where the arms are in relation to the rest of the body, where the tongue rests in the mouth)
  • Items in the field of vision (e.g. the nose, eye floaters)
  • White noise (e.g. the hum of a refrigerator)
  • The very presence of thinking taking place

Like any obsession, there is a fair amount of cross-over into other obsessions. Hyperawareness of the position of or sensations in the groin, for example, are a common issue for those with obsessive fears related to sexual issues. Hyperawareness of sensations in the hands, as another example, can be triggers for obsessive fears of harming self or others. The focus of this blog is primarily on the obsessive concern with the awareness itself.

What Are You Actually Afraid of?

In some cases it may appear that you are simply over-sensitive or have a low tolerance for specific discomforts, but in this form of OCD the problem is that the mind has become overly attached to a specific target and simply stuck there. Efforts to detach the mind from its target seem to have the opposite effect. Why this? You may wonder. In most cases, OCD gets you stuck on unwanted thoughts that are inherently disturbing (e.g. about illness or unwanted sexual or violent thoughts). People who suffer with those types of obsessions don’t want to be stuck there either, but with a sense of purpose. Who would anyone want to think such terrible things? What makes hyperawareness obsessions all the more frustrating is that the person experiencing the obsession is not only stuck, but feels stuck as if with no sense of purpose. Why am I thinking about my breathing instead of just breathing without thinking about it? However, it is not really the case that hyperawareness obsessions have no underlying fears. The seemingly innocuous obsession with unwanted awareness is just the surface of often much darker concerns. Some related obsessive thoughts include:

  • I will be permanently distracted by these thoughts
  • I will never feel what it felt like to experience this automatically, without conscious attention
  • I will be depressed forever because this thought will dominate my attention during meaningful experiences (e.g. my wedding and memories thereof will be ruined by my focusing on my blinking)
  • I will embarrass myself socially because I can’t pay attention to anything but these thoughts
  • I will have a mental breakdown, a panic attack, or become psychotic because of constantly thinking about this
More Compulsions Than You’d Think

People with these types of obsessions often assume that they are not doing compulsions because the experience is mostly one of lamenting the intrusive thoughts. I wish I wasn’t thinking about this! But actually many compulsions drive these types of obsessions and being able to identify and esist or interfere with them is key to overcoming this issue. Here are a few examples:

  • Mental checking to see if awareness is still present
  • Mental or physical checking to see if the sensation feels “normal”
  • Repeating the activities (e.g. blinking, swallowing, checking, etc.) a specific number of times or in a ritualistic way to give oneself permission to stop thinking about it
  • Relying heavily on distraction to avoid having the thoughts
  • Reassurance seeking that the awareness will go away or that it’s normal to be aware
  • Mentally reviewing how it must have felt before hyperawareness set in
  • Avoidance of environments or circumstances where awareness might become more pronounced
  • Mental rituals (e.g. chants, affirmations, neutralizing statements, etc.) to neutralize the fear of being permanently aware
Cognitive Therapy and Hyperawareness

At the core of these types of obsessions is the problem of over-protecting the present moment. It is what it is, but you’re concerned about ruining it. The idea is that if I am thinking about an involuntary or inconsequential process, then by definition I probably should be thinking about something else. Thinking about the last time I blinked or the next time that I will is the same as squandering attention that could have been placed somewhere more fulfilling or useful (anywhere). Cognitive therapy asks that you take these thoughts and challenge their assumptions. For example “I should not be aware of this” can be challenged as “I can’t control what’s on my mind and I don’t need more rules”.

Though “should” thoughts take center stage with hyperawarenesss, other common cognitive distortions can be recognized as well. Catastrophizing, for example, can come in the form of “If I don’t stop thinking about this my life will be destroyed”. Magnifying (relating to the thoughts or feelings like they’re a bigger concern than they are) also plays a serious role. Here, a thought like “Oh, no, I’m thinking about my breathing” can be challenged as “Right, so I think about my breathing. Breathing happens.”

Efforts to bring the way you perceive the problem back to an objective viewpoint can help reduce the intensity with which you may feel you have to get rid of the problem. The problem is, after all, not the problem it appears to be. OCD will tell you that the problem is you can’t stop thinking about your awareness. But the actual problem is that you are trying to control your mind. Loosening this control effort opens you up to accept uncertainty and expose to your fear that the uncontrolled mind will contaminate your life.

Exposure and Response Prevention and Hyperawareness

Like exposure and response prevention (ERP) for other forms of OCD, much of it comes down to doing willingly what your mind is doing against your wishes (exposure) and then resisting the urge to flee from the resulting discomfort (response prevention). Compulsive efforts to stop thinking about the obsession only seem to teach the brain that there is something special or interesting about the subject. Instead ERP aims to change the relationship between you and the fact that this thinking is occurring in this way. ERP for hyperawareness obsessions may typically come in the following four forms:

  • setting up reminders to bring your attention to the target of your obsession on purpose

Like a lot of ERP, this may seem counterintuitive or redundant. After all, you’re already spending a lot of time frustratingly noticing the things you don’t want to notice. However, your experience is almost exclusively on the defensive. The thoughts are intruding and you are trying to keep your cool, trying to make it stop, trying to distract. Lots of trying. By purposely bringing the thought to mind, you take an assertive stance and that means you are approaching ERP from the angle of practicing the work, not trying to avoid it. If the fear is obsessing forever, then trying to obsess denies the OCD its power position. Learning to let go of resistance to the idea that you may obsess forever is the best way to get to the other side and discover that this experience, like all others, is also impermanent.

  • writing scripts describing the consequences of being permanently aware

Imaginal exposures can be very effective in treating OCD, particularly if the feared outcome is undiscoverable until death. You won’t know if your life has been totally annihilated by your obsession until your life is, well, over. So taking the mind on a fictional journey through a life consumed by your obsession can effectively generate the sense of uncertainty and the emotional terror that comes with it. In a script like this, you could describe what you think it would really be like if this state of hyperawareness was a permanent upgrade to your operating system. The purpose of this exercise is to generate the urge to do compulsions so you can learn to be in the presence of this urge and not give in to it. Through this practice, you also learn to accept uncertainty because you do not automatically get thrown by your uncomfortable feelings.

  • agreeing with thoughts about permanent awareness

Taking the software upgrade metaphor further, agreeing with your unwanted thoughts about awareness in the moment is also an excellent strategy for breaking down the resistance that keeps the obsession alive. The OCD may say “You’re thinking about swallowing again and it’s going to take over your life!” You say, “You bet. The old version of me was relatively unaware of when or why I swallowed and how it felt, but Me 2.0 is always aware.” This approach takes the wind out of OCD’s sails and leaves it with little else to threaten you.

  • Putting yourself in likely triggering situations

Instead of trying to get to a distracted place where you feel free of your hyperawareness triggers, you can expose yourself to environments where triggers are likely to come up. One way to do this may be to consider what things you have already been avoiding. For example, engaging in social behavior can be an exposure if you have hyperawareness obsessions about eye contact. Meditating, especially in a style that focuses on the breath, can be excellent ERP for obsessions about breathing.

Mindfulness and Hyperawareness

The whole purpose of mindfulness is to increase your awareness of what the mind is doing in the present moment, so it may seem counterintuitive to use mindfulness as a part of treatment for hyperawareness OCD. But this concern reveals the actual problem with hyperawareness obsessions. You are aware that the mind is attending to something, so in a sense you are being mindful there, but you are missing the opportunity to also be mindful of the resistance to that attention. Instead of noticing the resistance as simply another object of attention, you are identifying with the resistance, which is feeding the OCD. In other words, the wish that you not think about [insert target here] is also something to be mindful of. In meditation practice, you can learn to identify resistance as an object of attention and notice when you are trying not to think something when it would be more skillful to simply observe that thinking is present. When you let go of the drive to stop thinking about your awareness, you may feel discomfort, a sense that the walls are closing in or your time is running out somehow. This discomfort is a feeling and, thus, subject to the same rules as any other object of attention.

People with hyperawareness or sensorimotor obsessions may feel isolated from the rest of the OCD community. It is easy to make the mistake of thinking that it isn’t OCD because the compulsions are not so visible or the subject matter is not so content-focused. But once you understand how the mind has gotten stuck, you can learn to stop doing what makes sense instinctively (the mental equivalent of flailing about in quicksand) and do the mindfulness and CBT work that can help you get grounded again.

Jon Hershfield, MFT is a psychotherapist in private practice licensed in Maryland, Virginia, and California, and director of The OCD and Anxiety Center of Greater Baltimore.  Follow him on Twitter and Facebook

The post Me 2.0: Navigating Hyperawareness Obsessions appeared first on The OCD and Anxiety Center of Greater Baltimore - Director, Jon Hershfield, MFT.

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by Molly Schiffer, LGPC

When I meet clients for the first time they often arrive at my office with some mixture of trepidation and despair, their suffering quite evident. They may have varying degrees of knowledge about OCD, but what they all share is this overwhelming feeling or urge to do something about their unwanted thoughts and eradicate or alleviate doubt and uncertainty. While often times the content of their obsessions falls into a subcategory such as harm, relationship, contamination, sexual orientation, pedophilia fears, or “just right” obsessions, this is not always the case. These subcategories are not all-encompassing nor are they always distinct from each other. However, what they do all share in common is the oh-too-familiar process of a thought arriving with an emotional jolt followed by the desperate attempt to get rid of the anxiety, and then always followed by an increase in the obsessive thought.

Compartmentalizing OCD

Identifying subcategories of OCD can be an effective way for clinicians to organize and describe specific manifestations of OCD. For individuals with OCD, having a label for their OCD is a way for them to join with others and feel a part of a group with fellow sufferers. When I attended my first International OCD Foundation conference I remember thinking how interesting it was when you would meet someone new and they would ask for your “brand” or “flavor” or “theme” of OCD. This is similar to the culture of Alcoholics Anonymous where people talk at meetings about being “daily” drinkers versus “binge drinkers”. What had once been a source of shame can serve as a way to end the isolation and loneliness many people with OCD experience.

That being said, I have also noticed a tendency of some of my clients to want to “perfectly” compartmentalize their OCD, or cleanly separate and label what is OCD versus another kind of anxiety. But OCD does not discriminate in regard to subject matter and one can have obsessions and compulsions about nearly anything. OCD sufferers can get duped when the content shifts away from some “obvious” OCD theme and into something masquerading as a potential “real issue”. “That’s not my OCD because it’s about something real,” they say. But trying to separate OCD from what they view as “regular” anxiety is part of the OCD trickery.

Is Or Isn’t My OCD?

This perceived need or urge to label and categorize different types of anxiety is actually a compulsion. By trying to be certain of what is or isn’t OCD you are also trying to feel more certain that you are getting the exact “right” treatment specific for the exact right anxiety. When OCD presents in a typical or obvious form, identifying it as such becomes a thing of comfort. “I don’t have to do compulsions because this is obviously my ‘Harm’ OCD.” But this focus on the content of the thoughts can sometimes make it more difficult to catch the more subtle forms OCD can disguise itself in. Here are some examples of OCD hiding in potential “real issues”:

Mary is 27 and was raised in a Christian home, but turned away from the church during her teen years. After the birth of her first child Mary began going to church again, and had been enjoying it despite the fact she wasn’t sure she agreed with all of the teachings, particularly the creation story. Mary began to wonder what she really believed in regard to creation versus evolution. Over the course of a session it became evident that Mary was stuck in the OCD loop of “I need to know exactly what I believe.” Mary stated this was a real issue because she wondered if she could be a Christian if she didn’t believe in the creation story. The OCD had her focused on her religious ambivalence instead of on “I need to know exactly…”

John is 29 and has been sober for a year. John was working the steps of a 12 step program. John was doing a daily inventory which was part of his step work. The purpose of the inventory was to look out for places where he had been dishonest or selfish so that he didn’t slip back into old behavior and pick up drinking again. As John continues to practice writing his daily inventory John became unclear about his motives in situations and whether he had been selfish or dishonest. John began to spend excessive amounts of time writing and re-writing his inventory as he wanted to be thorough. John felt that his concerns were real issues because his sobriety might be on the line. OCD had him focusing on the content (his very real sobriety) and not on the obsessive drive for certainty about his motives and the compulsive re-writing.

Sara is 36 and recently gave birth to her second child. Sara loved being a mother, but found her second child to be more challenging to care for than her first. Soon Sara began dreading those moments when her baby would cry and Sara would become frustrated. Sara had a great experience with her first child who slept through the night and seemed content most the time. Sara became concerned about her feelings and whether she loved her children the same. Sara wanted to be sure she cared for her children equally and felt that she might need to explore the issue further to make sure she was being a good mother. This resulted in hours of ruminating on whether she was certain she loved her child the right way. OCD had her focusing on her frustration with a more challenging child and not on the compulsive mental review and attempts to be certain she is having the “right” feelings.

These examples highlight three subtle manifestations of OCD focusing on belief systems, motives for behavior and feelings. These sufferers may find themselves continuing to engage in compulsions without insight because of the assumption that the content of their concern doesn’t clearly fit an OCD theme. OCD loves to poke OCD sufferers on content that is inherently riddled uncertainty. The idea that one needs to pin down beliefs, motives or feelings is black and white thinking, a cognitive distortion that often propels OCD sufferers to look for a singular truth when often people have multiple conflicting beliefs, motives and feelings.

Unanswerable Questions

What I find helpful when working with clients who get sidetracked by content that is disguised as a potential “real issue” is to revisit the idea that OCD is not identified by the subject matter but by the process of how the thoughts arrive with a feeling of import and urgency, almost like receiving a message of warning. A telltale sign that you have entered OCD territory is when you are asking a question of yourself that can’t actually be answered. Some examples of unanswerable questions:

  • How do I know exactly what I believe?
  • How do I know this is my OCD and not a real issue?
  • What does this mean about me?
  • How do I know with 100% certainty that I am getting the right treatment?
  • What if I am not relaying the content of my obsession sufficiently and get the wrong type of treatment?
  • How do I know that this time it’s not true?

It is important to recognize these subtle yet familiar processes and not be fooled by the lack of creativity in the content. In other words, the way in which you think is a better measure of OCD than the details of what your thoughts and how bizarre or “normal” they appear.

“OK, so what should I tell myself then?”

When I respond to clients with, “don’t tell yourself anything,” they often look completely dumbfounded. The idea of not saying anything at all seems ludicrous, maybe even impossible. “But I have to tell myself something!” they reply. However, that behavior is driven by a secret (or not so secret) hope all OCD sufferers have, which is to get rid of these thoughts and feelings, and that means the behavior is compulsive. The hope is that with saying the “right” thing to yourself or applying the “right” strategy you will get rid of the unwanted thought for good. This is when applying a “strategy” itself becomes a compulsion. No matter what strategy you use or what you say to yourself, if your goal is to make thoughts go away, it will fail due to the paradoxical nature of anxiety. Trying to get rid of it teaches the brain that it is important, dangerous, and must be the focus of attention.

Thoughts actually don’t require us to do or say anything at all. They are not intrinsic messages or mandates to act. The fact that the content of the thoughts has shifted to something that feels more like a “real life” issue, does not make them operate any differently from any other OCD process. When I see clients stuck in “Well, that thought was obviously OCD, but what do I do about this thought?” I usually recommend that they put away their books on anxiety and OCD and start doing the hard work of putting less effort into their recovery.

The Paradox of Doing Less to Achieve More

Doing less means letting go of the whack-a-mole approach to OCD, of jumping from one scary thought, concluding it must be OCD nonsense, and then jumping to the next scary thought until that one has been neutralized. Instead what is needed is a shift in attitude and mindset; a move from “I have to get rid of these thoughts” towards a stance of “I can get better at accepting mental chatter as it comes and goes.” Sufferers can strive to recognize that the volume (or loudness) of the subject matter or content is not an indicator of its importance. We all walk around with a degree of mental chatter or “the committee,” a term used by members of Alcoholics Anonymous to describe their awareness of the mental activity going on. What sets apart the OCD sufferer from those without the condition is the OCD sufferer’s acute awareness of the chatter and the predisposition to judge or attribute meaning to the chatter.

Sometimes I like to ask my clients to stop and consider who is asking these questions and who are they responding to? The response I usually get is, “I don’t know.” There is only one person involved here and it’s you. The mental gymnastics that takes place in trying to prove what is OCD and what isn’t may seem like real problem solving and self-searching but it is in fact just OCD in disguise.

I find it helpful to think of my mind as having radio channels that are pre-set. Some of these channels play desirable thoughts and other times they play undesirable thoughts. Chances are that at any point I can tune in to a channel and find these unwanted thoughts no different than walking into the mall and hearing the Chumbawamba song…”I get knocked down but I get up again…(sorry, can’t stand writing it either) for the gazillionth time. The point being that my level of misery will directly correlate with how much I am tuning in to the channels and how much effort I put into trying to change the channel or get rid of my awareness of it.

Bumper-to-Bumper or Smooth Sailing

The message I hope to impart is that one can make room for all types of thoughts. Imagine you are driving home in rush hour after a long day at work. In rush hour you’d likely see a multitude of vehicles of different shapes, sizes and colors all keeping you from arriving home. Sure, you could beep your horn and scream in frustration or you could accept that there are a lot of cars on the highway making movement difficult. Similarly, one can learn to accept that they are human and humans have a lot of different kinds of thoughts that don’t require any special attention or specific response.

Don’t let OCD trick you into taking the bait by seeking certainty about the content of your thoughts and debating about whether the content is OCD or a “real” issue. Instead, look to how you are thinking, and look at the the way in which the thought arrives with that feeling of import.  These are your best clues that OCD is involved. I often tell my clients that if you are asking whether OCD is involved or whether there’s a “real” issue, go ahead and treat it like OCD because chances are the question itself is the OCD. Don’t wait to be sure it fits into a category, don’t try to be certain, but beat the OCD at its own game by taking the risk and letting all vehicles in traffic flow.

Molly Schiffer, LGPC is a psychotherapist specializing in OCD and related disorders at The OCD and Anxiety Center of Greater Baltimore.

The post Help! I Have OCD About What’s OCD! appeared first on The OCD and Anxiety Center of Greater Baltimore - Director, Jon Hershfield, MFT.

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I recently gave a talk called “Obsessive Fear of Violence in OCD” at a psychiatric conference. My talk was part of a panel on gun violence in the United States and what psychiatrists should know about it. The other speakers discussed gun violence statistics, the role of extremist violent organizations, and the link (i.e. lack thereof) between gun violence and mental health diagnoses. Then there was me, talking about people who are terrified of violence, frightened by unwanted intrusive thoughts of violence and fearful of what they could mean. I was a bit worried that talking about OCD on a panel about gun violence could send a confused message, but part way through listening to the other speakers I realized we were all talking about the same thing, that human beings are impacted by the role of violence in society and that treatment providers need to understand how different people are impacted differently.

In the weeks leading up to my presentation, I started taking pictures of newspaper headlines, thinking a collage of triggering “Man Kills Many People” stories would highlight what Harm OCD sufferers are triggered by every day. It took less than two weeks for me to have too many headlines to fit on one slide. The day I decided to stop collecting new headlines, I opened the newspaper to “59 Killed in Las Vegas Attack.” As of this writing, the motive of the man who shot at innocent civilians from the window of his Las Vegas hotel room remains unknown. You don’t need OCD to find this unsettling. Someone killed a lot of people, with no warning, with unknown intentions. This doesn’t prove that the world is any more dangerous than it was before this incident, but it does prove that living with uncertainty simply cannot be avoided.

Consider the following OCD traps that may await an incident like this. If someone can do this for no known reason, couldn’t the reason in fact be no reason? What does this say about me as a person with violent thoughts? I have no reason to act on my unwanted thoughts, but what if I decide to act on my unwanted thoughts anyway? Would I do that? Could I do that? These types of personalization traps (viewing events as being related to your obsession) may cause you a lot of pain, with one unanswered “what-if” following another. Furthermore, the general public’s thirst for answers often leads to a lot of loose talk about “mental health issues” as the cause of violent acts in the news. We may be accustomed to staying glued to the tv for information about current events, but studies have suggested that the more people watch television, the less they are likely to actually know about OCD and the less people know about OCD, the more they were likely to believe that people with OCD were violent. (Kimmerle and Cress, 2013) So with the cards stacked against you, consider the following useful things to remember:

Be mindful of facts: OCD wants you to focus on theories, but this is a distraction from facts. What are the facts of an event like the Vegas massacre? A man who is not you did a thing that you have not done in a place that you are not in for a reason that you do not know and this is making you uneasy. These facts may not bring you immediate anxiety relief, but they are nonetheless accurate reflections of what is going on in the present moment. That means they are subject to observation without judgment and that means you have the choice to access mindfulness.

Be mindful of perspective: Every day I sought a scary headline, I found one because every day something terrible seems to happen somewhere. This is true. However, I am looking in a newspaper. News, even done at its most ethical, is designed to highlight things of interest. Violence is interesting, not just philosophically, but because it is statistically rare. If I open the paper to find a crossword puzzle, that is not something I need to share. If I open the paper to find a million dollars (or rabid raccoon), well, that’s news. Bad things happening are worth our attention, of course, but learning of bad things happening does not mean bad things are happening at all times in all places. OCD wants you immersed in the content of “harm” and wants you to forget that most of the time, you are either bored because nothing new is happening, or satisfied and don’t know it.

Be Mindful of self-absorption: To be “self-absorbed” sounds like an insult, but taken literally, it just means to be absorbed with oneself. That is, OCD has a way of creating a black hole around your identity, where information is constantly being pulled in and nothing comes out. Your Harm OCD is likely to tell you that any event in the news related to your obsession is somehow secretly about you, whether it’s an act of terror, a celebrity suicide, or murdered child. The OCD tells you that you have a moral responsibility to investigate triggering news stories to figure out exactly how they apply to you. But these events are about the people that were actually involved in them, not about you. Try to go against the OCD by taking the focus off of what it means for you and putting it on what it means for those involved or society as a whole. Or, of course, on the taste of the sandwich you were eating before you got triggered by the news.

Most of us are engaged in some form of social media or another. Social media newsfeeds can be a scary place when you have OCD. Though avoidance is rarely the answer to dealing with triggers, this does not mean you have to always go out of your way to put yourself in unnecessarily stressful situations. Scrolling through newsfeeds, especially around the time of a recent violent event in the news, is going to give you lots of things to check. It’s easy to get stuck in a trance and hard to pull yourself out of it. But living with OCD doesn’t mean you have to do without the things you care about. For those genuinely interested in current events, I recommend streamlining your news acquisition to something static, like a print newspaper. All the same rules apply, no checking, no reassurance seeking, etc. But without the prompts to click and click your way down the rabbit hole, it is a lot easier to remain mindful of what you are choosing to expose yourself to.

It’s easy to fall for the trap of thinking your life would be better without the triggers in it. That’s the OCD pointing you at the content of your thoughts (beyond your control) and away from the process or how you relate to your thoughts (within your grasp). Gaining mastery over your OCD, or gaining mastery over any challenge, means reconciling what’s good for you with what makes you feel good. It’s up to you to decide what you value, but what you value should not be avoided even if it makes you uncomfortable. Go into experiences with open eyes and be mindful of what triggers bring up for you. If you want to read the news, read the news. Do your best to read it without OCD lenses, and take the risk of being self-compassionate when OCD sometimes makes this difficult.

References:

Kimmerle, J., Cress, U. (2013). The effects of TV and film exposure on knowledge about and attitudes toward mental disorders. Journal of Community Psychology, 41, 931-943.

More on Harm OCD:

Click here for Harm OCD: Part One

Click here for Harm OCD: Part Two

Click here for Harm OCD: Part Three

Click here for Harm OCD: Part Four

Jon Hershfield, MFT is a psychotherapist in private practice licensed in Maryland, Virginia, and California, and director of The OCD and Anxiety Center of Greater Baltimore.  Follow him on Twitter and Facebook

The post Coping with Triggering News Media When You Have Harm OCD appeared first on The OCD and Anxiety Center of Greater Baltimore - Director, Jon Hershfield, MFT.

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by Molly Schiffer, LGPC

Loving someone with OCD can be a gut-wrenching experience. When a loved one receives a diagnosis of OCD and begins treatment, this may come as a tremendous relief for the family. Often family members have watched their loved ones suffer for years prior to them getting the right diagnosis. Whether it’s your parent, spouse, child or sibling, you know the pain of watching OCD overtake your loved one to the point that they are just a shell of their former self. At first there are the attempts to appease the OCD, hoping to ease their pain. But then you discover that not only does your loved one seem to get worse, but OCD rituals also increase. Even when you realize that what you are doing isn’t really helping them, at least it seems to keep them surviving while allowing you to address the needs of other family members. This is especially true if there are children in the home who still need to be cared for and have their needs met. The name of the game becomes survival and all joy can be lost.

The Whole System
Years of living with someone with OCD causes significant disruption to the family system, so much so that the family member with OCD begins to feel like a burden. The personal journey that led me to specialize in the treatment of this disorder started with me growing up with a mother who had severe OCD. Back then, help wasn’t readily available and few people understood OCD. Trying to help someone with the disorder is a lot like being a hostage negotiator. It can make you feel like you have to meet OCD’s demands in order for your loved one to be released long enough for them to go to school or work or join the family for dinner.

My mother’s OCD often kept her consumed by fears of disease. Some of my earliest memories include investigating moles on my mom’s head for changes in color and size which she worried could indicate melanoma. I remember jabbing myself in the ear repeatedly with a Q-tip to see if it caused pain just so I could prove to her that everyone feels pain if they stick it too far down the ear canal. I even found myself spinning in circles in order to reassure my mom that it was normal to get dizzy if you move your head too quickly. These events were all part of everyday life living with someone with OCD, of the hostage negotiation that I lived through. In doing these things I thought I was helping her, doing what I could to allow her to be part of the family on whatever level she was capable. I wanted so badly to ease her suffering.

It’s Not Your Fault
While I understood intellectually that her condition wasn’t my fault, in my heart I felt guilty for ever experiencing joy at the same time that I knew my mom was suffering so much from her OCD. I felt selfish for wanting to have friends over or even asking my mom or dad for things I needed because I was so afraid to add an extra burden to their already burdensome lives. For many years I thought that trying to help by providing reassurance that her fears weren’t true was the right strategy. I have since learned that the very strategies I was using out of love were actually making things worse. They ultimately increased her inability to tolerate uncertainty, increased her overall anxiety, and ensured that she would remain on the hamster wheel that is OCD.

Since that time I have had the opportunity to learn, both in training and in clinical practice, that the most loving response to a family member with OCD is to not participate in their compulsions. The key is understanding how to do this while at the same time remaining compassionate and supportive. It is important for families to know they didn’t cause the OCD and they can’t cure the OCD. However, they can learn stop contributing to the maintenance of the OCD. I have been amazed by the resiliency and courage of the families I have worked with and with the right tools, family members and OCD sufferers can work together as a system and change the trajectory of what once seemed like a hopeless situation.

Molly Schiffer, LGPC is a psychotherapist specializing in OCD and related disorders at The OCD and Anxiety Center of Greater Baltimore.

NEW SUPPORT GROUP FOR FAMILY MEMBERS
At OCGB we are now offering a psychoeducation support group specifically for families of individuals with OCD. Participants will learn about the disorder and how to support family members without getting wrapped up in their OCD behaviors and becoming part of what keeps them stuck. Check out the flyer below for more information on our program.

The post Truly Being There for a Loved One With OCD appeared first on The OCD and Anxiety Center of Greater Baltimore - Director, Jon Hershfield, MFT.

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Lately the blogosphere and the online support groups seem to be filling with questions about so-called “false memories” in OCD.  In fact, I can tell when it’s time to explore an obsession deeper when people start using it as a whole new label:  False Memory OCD.

False Memory OCD refers to a cluster of OCD presentations wherein the sufferer becomes concerned about a thought that appears to relate to a past event.  The event can be something that actually happened (but over which there is some confusion) or it can be something completely fabricated by the mind.  It is not exclusive to any specific subcategory of OCD, but I see it talked about the most with people who are afraid of being sexually inappropriate or having committed some other irresponsible, immoral, or harmful act.  Here are a few representative examples:

  • A dad changes a diaper and afterwards an image pops into his head of having fondled his child’s genitals in the process. He knows he would never do such a thing, but the image is vivid.  He wonders, is that just one of those random nonsense intrusions I get with OCD or is that a memory of a bad act I committed?  He plays the image over and over trying to prove that it is not a memory.  When this fails to relieve him of discomfort, he returns to the child’s room to check for further proof that the child has not been harmed.  Since he is unable to identify anything that proves harm one way or another, he tries to mime changing the diaper again and asks himself if that feels more like his actual memory of changing the diaper than the image in his head of having done the bad act.  This also proves unsatisfying and he begins to worry that he will never be able to feel confident again that he has never harmed his child.
  • A woman spontaneously recalls a night from years ago when she went dancing at a nightclub with friends. An image pops into her head of having been in the bathroom and crying about something.  She can’t remember what it was that she felt upset about.  She can picture herself looking in the mirror and feeling unhappy.  Did she cheat on her boyfriend?  Was that it?  Did she kiss another man that night?  She can’t remember doing that, but then she can’t remember exactly what bothered her.  Wouldn’t she know if she had cheated on her boyfriend?  But then she must have been upset about something, what was it?  Or was she even upset that night?  Could this image of crying in the nightclub bathroom just be a glitch in her memory or does it mean she blocked out something unforgivable?
  • A man uses a restroom at the airport before boarding his flight. As he leaves the restroom, an image pops into his head of having a gay sexual encounter.  The next thought that comes to mind is, “what if that image is a memory of  something I did in the bathroom stall with someone?”  He tries to ignore it, but can’t resist the urge to go back into the bathroom to see if there are any men in there that confirm or deny the image as a memory.  This proves unsatisfactory because he can’t be sure of the face in the mental image.  He tries to let it go and board the plane, but during his flight he begins to worry less about the potential that the act actually occurred and more about the idea that he may convince himself that the act occurred and start to believe that the thought is a memory.  He imagines this mental error causing a range of problems in his life, including fearing gay denial, depression, and developing a pattern of convincing himself of other things that aren’t true.

The Morality of Uncertainty

To begin this discussion, I think we need to be careful when coming up with new titles for obsessions.  OCD is OCD, so calling something “False Memory OCD” is already giving power to thoughts that the thoughts don’t deserve.  OCD is a disorder that involves unwanted intrusive thoughts and a struggle to accept uncertainty about their meaning.  So there’s nothing unusual about thoughts that begin with “what if I did…” that separates that from “what if I will…” or “what if this means…” or any other what-if that comes up.

False memories are natural phenomena that occur in the mind from time to time.  They are mental events that are perceived to be true about the past but are in fact false.  There is reason to believe that people with OCD do actually experience more of these types of memories than the non-OCD population and that people with OCD tend to rely more heavily on a feeling of familiarity to assess whether a memory is true or a false. (Klumpp et al 2009)  So false memories (such as thinking you put your sunglasses on your desk when you really left them in your car) really may occur more for people with OCD.  But often what we have come to call “False Memory OCD” is not so much about the presence of false memories but about the need to be certain about the truth or falseness of our thoughts.  In other words, the obsession is often a morality concern over whether it is ok to be uncertain about the veracity of the images in our heads.

Is it ok to not know for sure if the thought in your head of having harmed a child is a true memory or a false memory?  Can a “good person” just shrug and move on?  Further, is it a memory at all or just a thought about what could be a memory?  If I have a thought that I didn’t wash my hands earlier:

  1. it may be a true memory of having walked by the sink in complete disregard of my hygiene (it probably is)
  2. it may not be a true memory (I might have washed my hands and think I didn’t by accident)
  3. it may be a thought that corresponds to no point in time, but just presents as a random image in my head (like most of my thoughts)

Those suffering with this obsession want to know perfectly clear distinctions between these three presentations of thought in the mind.  Like all OCD, the disorder tries to get you caught in the weeds of the content of the thought rather than looking at the process of how you are relating to your thoughts.

Lack of Memory Confidence

Many of these types of obsessions, though not all, spring from a heightened lack of confidence in memory.  People with OCD are often doubtful of many things, including the veracity of their memories (did I mail that letter?).  If this concern is heightened by experiences that corrode our memories, obsessions may be more intense.  For example, a night of excessive drinking can result in memory gaps or blackouts.  This gives the OCD ammunition to say something bad happened without you being able to defend yourself by saying you think you remember otherwise.  You actually don’t remember in this case and can only rely on assumptions based on historical behavior.  But even if you don’t drink to the point of blacking out, you may still know that you drank some and that this may have interfered in some memory retention, again fueling the OCD.  Along these lines, memories from childhood can be rusty, so this opens the door for OCD to suggest that there are things you could not accept hidden somewhere in your subconscious.  Since there are undoubtedly gaps in your memories from ten or more years ago, the OCD can point at those gaps and try to fill them with nonsense.

All this being said, so-called “false memories” can be the product of spontaneous intrusive images tagged with the question “is this just another intrusive thought or is it a memory of something I did?”  They can also be a product of relatively uninteresting memories that have been distorted by compulsive mental review, much like overplaying an old audio-cassette.  Repeatedly reviewing a thought (whether it is a memory or a random image), actually changes it and again chips away at your confidence in assessing it.  Memories are not digital photographs of experiences, but actually complex combinations of data from all of your senses filtered through your emotional lens at the time you experienced the event.  Looking at the same data later from another emotional state (e.g. terror that you may have done a bad act) actually changes the memory itself.

Compulsions

All compulsions for false memory fears boil down to trying to prove with 100% certainty that an unwanted thought is not a true memory of an unwanted event.

  • Mental review, mental review, mental review. The king of compulsions for so-called false memories is quite simply spending mental energy trying to make the distinction between a memory (the thing you don’t want it to be because it will mean you’re not worthy of being happy ever again) and an intrusive thought (the thing that you want it to be because it just means you have a debilitating mental illness).  Mental review is both the hardest and most important compulsion to resist.  Often you can’t preempt it, but the moment you notice you are doing it, you need to label it and jump off the mental train.  Some people wash their hands, others try to wash their moral fiber, and reviewing an unwanted thought to assess its significance is a major mind wash.
  • Checking can be literal as in checking to see if the thought is a memory by going back to the location where the thought originated to see if any evidence supports it being a memory.  Checking can also come in the form of researching people online to make sure they were not harmed by the imagined event.  It can also be more abstract, such as mentally checking to see if the thought feels more like a memory now than it did an hour ago.  Research into this has suggested that repeated compulsive checking has been shown to reduce trust of one’s memories. (Radomsky et al 2006)
  • Reassurance-seeking. Bringing other people into the mix (that is, other people who are not your OCD therapist) is rarely a good idea.  People who care about you struggle to watch you squirm under the OCD and know that all they have to do is tell you it’s OCD nonsense.  But this sends the message back to the brain that the thought is something more than a thought.  Why else would you need to be reassured?  Furthermore, efforts to collect objective information (e.g. texting people who might have been a witness to the event) are very likely to backfire because the answers are rarely satisfying, leading to more questions than relief.
  • Confessing. This form of reassurance seeking (collecting reassurance through the reactions of those who receive your confessions) may sound like “I just want you to know that I may have done xyz”. This can also involve a variety of mental rituals that include imagining confessing your crime/sin or engaging in mental debates over whether something should be confessed.

Treating False Memory OCD

First, stop calling it False Memory OCD.  It is no different than calling it Unsure About the Content of My Thoughts OCD which might as well be called OCD OCD OCD.  To understand how to tackle any manifestation of OCD, you have to understand a few core concepts:

  • You don’t control what thoughts show up and when
  • Everyone desires certainty that their fears are untrue but what sets people with OCD apart is the amount of life they are willing to sacrifice for this futile endeavor
  • Everything you do to prove the thought untrue makes it seem more familiar and therefore more real
  • It is not possible to know what one’s intentions were, only what they are in the present moment

The reason why this manifestation of OCD sometimes appears more difficult to treat is because it really combines an obsession with the past and an obsession with the future.  There is an unwanted thought about a past event, real or imagined.  The person with OCD wants to know that the event (or the worst possible version of it) did not occur.  To tackle this obsession, the OCD sufferer has to stop trying to get certainty, which means ceasing/interfering in compulsive mental review, doing exposure to the idea that the event may have been exactly as imagined in its worst form, and letting go of all efforts to seek reassurance.  In other words, like a lot of OCD therapy, a very fancy way of saying “whatever happened, happened and let’s move on.”  Here’s where things get tricky.  The moment this is attempted, it stirs up a related obsession, namely, what if I am a bad person simply choosing to live in denial of a bad act in the hopes that I don’t get caught?  Fear of confronting this possibility can push susceptible people back into their old patterns of reviewing their memories and trying to get certainty about them again.

This way of OCD trapping you between one unacceptable reality and another may sound familiar.  Consider that people who obsess about sexual orientation often oscillate between the fear of being gay and the fear of avoiding having to live as a gay person only by being in denial about being gay.  Treatment, therefore, needs to operate along both fronts.  The sufferer has to identify and abandon the review of the perceived past and eliminate all forms of reassurance, but also has to do exposure to the idea that doing so may reflect denial or a moral failure, a possibility that they may have to learn to cope with.  Fear of not being able to let go of the false memory is as potent as fear of the false memory being true.  Efforts to treat the memory obsession without also treating the fear of not being able to live with the possibility that they let something bad simply fade into the past will likely result in relapse.

Because “false” memories are sandwiched between presumably “true” ones, the OCD may place the cruelest demand of all on you, to be certain of your intentions in the past.  If I remember sitting in a chair and then I can’t remember what I did after that, then what were my intentions when I got out of the chair?  Compulsive efforts to answer this question and start investigating only lead to further doubts about what happened in that memory gap.

Some exposure strategies that may be helpful:

  • Writing imaginal ERP scripts in which you describe the false memory being true
  • Writing scripts in which you describe coming to the conclusion that the false memory is true and having to live with the memory of a bad act that is in fact not true
  • Writing scripts about not having OCD and instead living as a fugitive from taking responsibility for your (imagined) bad act
  • Engaging in behaviors that trigger false memory concerns (e.g. changing diapers if you fear false memories about harming children)
  • Spending time with people who you obsess were or could have been impacted by the imagined act

Cognitive considerations

Challenging and reframing distorted thinking can be tricky with false memory fears because the key to beating the obsession is to stop working on the thinking.  That being said, emotional reasoning (the distorted belief that things are true primarily because they feel that way) obviously plays an important role here.  If your calling out the emotional reasoning helps you step back from responding to the thoughts with compulsions, then it might be worth noting.  Magnifying, or viewing things as more important than they are, plays a key role here too since the obsession thrives on the belief that the presence of the thought alone is a big important reason to engage in compulsions.  And of course catastrophizing, the assumption of negative outcomes that can’t be coped with, is common here, especially when the fear presents as an obsession with getting stuck with a false memory or never being happy without resolving it.

Mindfulness

False memory obsessions are a mindfulness problem.  No “doubt” about that.  If mindfulness is the state of non-judgmental observation of your thoughts and feelings, then concern with false memories is a deficit of mindfulness and little else.  Mindfulness is not a tool in the sense that it is something to be “used” in fighting a thought or getting it to go away.  Mindfulness is a skill and as a skill it can enable you to expand your mind wide enough to make space for any thought, feeling, or combination thereof.  To be mindful of your false memory obsession is to acknowledge that you are grappling with a thought and thoughts are not necessary to fight with.  Thoughts are there to be observed as they pass by, but you have to let them pass by.  These thoughts about some terrible thing you may or may not have done, over which your salvation depends on some elusive label (“intrusive thought” or “memory”) are really just interesting ideas.  You noticed an interesting idea and you noticed that it came with a drive to eliminate it.  What if this thought is not just the typical OCD junk I experience with some regularity, but is actually a memory of some terrible thing I did?  What if I let it just be a thought and I’m wrong?  Who does that make me?  That is an interesting idea indeed.

But maybe it’s not really all that interesting.  Maybe it’s a con.  Maybe it’s just OCD doing what OCD does best, baiting you into distraction.  In the end, you have to be willing to guess like everyone else about the content of your thoughts.  Chances are if it didn’t bother you then, but it bothered you later, it’s OCD.  If you take that chance, you might find that the baited question of whether this is an intrusive thought or a memory is not so interesting after all.  You might be willing to do the hardest exposure there is and commit to treating OCD like it’s OCD and take the risk of acting as if all this junkmail in your head is irrelevant even when it feels like it could be something else.

Referenced:

Klumpp, H., Amir, N., & Garfinkel, S. N. (2009). FALSE MEMORY AND OBSESSIVE–COMPULSIVE SYMPTOMS. Depression and Anxiety26(5), 396–402.

Radomsky AS, Gilchrist PT, Dussault D. Repeated checking really does cause memory distrust. Behav Res Ther. 2006;44:305–316.

Jon Hershfield, MFT is a psychotherapist in private practice licensed in Maryland, Virginia, and California, and director of The OCD and Anxiety Center of Greater Baltimore.  Follow him on Twitter and Facebook

The post Did We Already Discuss False Memories and OCD? appeared first on The OCD and Anxiety Center of Greater Baltimore - Director, Jon Hershfield, MFT.

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It’s been an exciting few months for The OCD and Anxiety Center of Greater Baltimore! We recently moved into a larger space in the Executive Plaza complex in Hunt Valley, MD and are very happy in our new home. Our free “GOALS” OCD support group has been flourishing and continues to meet every other week. I recently became licensed in Virginia, allowing me to offer teletherapy services to people in that state (in addition to Maryland and California).  We also recently began offering week-long intensive treatment as a team, allowing for OCD and anxiety sufferers from all over to receive several hours of ERP treatment daily in a time-limited format.

Speaking of team, I am pleased to announce the newest addition to our center, Molly Schiffer, LGPC. Molly comes to us with a strong CBT background and an in-depth understanding of OCD treatment. Training her to work with our clients in the mindfulness-based cognitive behavioral format we are known for has been easy. Molly will be seeing individual clients at a reduced fee and will also be assisting our support group. Here’s a bit more about Molly:

Molly Schiffer is a Licensed Graduate Professional Counselor who has experience using Cognitive Behavioral Therapy, Mindfulness and Motivational Interviewing in the treatment of anxiety disorders, depression, trauma and substance abuse in children, adolescents and adults. Molly has experience in using individual, family and group modalities. Molly’s approach to therapy is to instill hope and self-compassion while increasing client’s own motivation to make difficult changes.

Molly believes in having a strong therapeutic relationship based on trust and mutual respect. Prior to joining The OCD and Anxiety Center of Greater Baltimore, Molly provided individual, family and group therapy to children, adolescents and adults in both clinic and in-home settings. Molly’s decision to pursue a master degree in counseling psychology was based on her longstanding interest in the treatment of OCD and other related disorders. Molly believes that people with OCD and other related disorders can live full happy lives with the proper treatment to address their OCD and the willingness to endure short-term discomfort for long-term gains.

So, there you have it. The OCD and Anxiety Center of Greater Baltimore welcomes Molly to the team as we celebrate our new office and continue to expand affordable individual and group services to individuals and families affected by OCD and anxiety. Check back on our website from time to time for new blogs on the blog and media pages, upcoming events, and new services.

The post New Office and New Team Member: OCGB Welcomes Molly Schiffer, LGPC appeared first on The OCD and Anxiety Center of Greater Baltimore - Director, Jon Hershfield, MFT.

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One of the questions that often comes up both in my clinical practice and in the online support groups I contribute to is, “How do I respond to my thoughts?” Or more specifically, “What is the right way to respond to my thoughts?” There is a hidden OCD trap here in the search for the exact right way to respond to thoughts. If we can be certain about the one true or “best” response to thoughts, it means that thoughts themselves have one true nature. If we can fail in our response to thoughts, the implication is that thoughts have an intrinsic power, a quality that must be carefully examined. Yet this idea actually flies in the face of the central thesis of OCD mastery, which is that thoughts are thoughts, not threats. The significance of their content is attributed to them, not hidden in them, and whether they are “worth” incorporating into some behavior or better left alone is not the sort of thing that fits into a concrete equation.

Ultimately, I don’t believe there is a best practice for responding to thoughts (OCD or otherwise).  There are practices that I see working better for some people and for others not so much.  There are practices that have a higher success rate (if we are associating the reduction of suffering with success) and practices that only work every once in a while in specific situations. Any practice done by rote, or done every single time, especially if done in a sense of urgency, can quickly turn compulsive.  Here are some options for responding to thoughts along with their potential pros and cons for OCD mastery:

Doing nothing

One of my favorite things to do in general, or at least it would be if I ever did it for very long. Nothing. In terms of thoughts and the responses we give them, doing nothing means completely ignoring thoughts as meaningless chatter, no different than the ambient noise of traffic from a distance. How can we do nothing in response to thoughts? Well, first, we have to believe that nothing is happening. Easier said than done. Doing nothing in response to a thought means not even taking a moment to acknowledge that the thought (or feeling or sensation) has occurred and simply plowing through your chosen activity as if unaware of any competition for your attention. It’s the “Keep Calm and Carry On” of navigating OCD.

Pros of doing nothing:

  • It treats the thought like the non-event that it is.
  • It stays out of the content of the thought altogether.
  • It wastes as little attention as possible.
  • It may enable the completion of tasks otherwise disrupted by OCD.

Cons of doing nothing:

  • It requires one to be in a state of mindful acceptance from the start, which is a major challenge for most people.
  • It can easily become a form of compulsive avoidance, a refusal to acknowledge that the thought occurred in the first place and a refusal to experience feelings as they are.
  • Active “ignoring” can trigger an additional sense of being in denial (and thus more anxiety).
  • It can quickly devolve into a habit of “white-knuckling” through life, which is unsustainable.

Mental noting

In a basic mindfulness meditation practice, mental noting means labeling the internal activity that is occurring in the moment one becomes distracted from their anchor (usually the breath). So, for example, if I am meditating and I notice how bored I am, I might gently say to myself, “boredom,” and then return to watching my breath. If I notice that I’ve wandered off into a train of thought, I may say, “thinking” and gently hop off the train as best I can. Similarly, when just going about my business in life, I may become distracted by an obsessive thought. I might respond to this as well by saying “thinking.” Or I could be more specific and acknowledge when the thought applies to a particular OCD concern, as in “murder thought” or “disease thought.” Once acknowledged, I then return to whatever I was doing before I became distracted (as in, going back to a specific activity) or I incorporate feeling distracted into that activity (do what I was doing but with somewhat divided attention). The point is I release myself from acting on the thought in any way past noting its existence.

Some may find it useful to mentally note “OCD thought” but I generally do not recommend this. By drawing distinctions between OCD thoughts and other kinds of thoughts, we are already playing into the distorted belief that the content of the thoughts has intrinsic value. If we must disown thoughts by calling them “OCD”, then we are saying we would be bad for having them without OCD. But they are thoughts, not threats. So even the worst thoughts are better off being understood as ours. This doesn’t mean that we like them or that they represent us, but simply that we have minds and minds have thoughts.

Pros of mental noting:

  • It’s honest about the experience of having the thought but without getting too deep into content and without acting directly on the thought.
  • It often lightens the sense of doom by positioning the thinker as an observer of thoughts instead of a victim.
  • It renders the debate over whether a thought is “good” or “bad” completely pointless.

Cons of mental noting:

  • It does give the thought some attention and for some this could lead to too much attention.
  • It opens up a window to covert mental rituals and can become a compulsion itself (e.g. having to accurately label the thought every time or checking to make sure you’ve noted everything).

Agreeing with the uncertain potential

Most obsessive thoughts come in the form of “what-if” questions like “What if I hurt someone?” or “What if I get a disease from having touched this?” Those that don’t present this way often still involve concerns like “what if I can’t tolerate this?” Given that certainty is a myth, it is reasonable to say that if we can think it, the likelihood of it also being a true about reality is something greater than 0%. It may not be much greater (as in, the ceiling above me may collapse at any moment but probably won’t), but it is nonetheless something other than an impossibility.

So if we were to respond to an unwanted thought with a statement like “That may or may not occur” or “I don’t know” or “Anything’s possible, but I have other things to attend to at the moment”, we are noting that the thought is present, owning that it is ours, and accepting that it has some amount of potential to be connected to reality. Other responses in this vein could include commenting directly to the OCD as in, “Duly noted” or “Mysterious” or “Well, that’s an interesting idea.” To be clear, this is not agreeing that the feared thought is true, that the feelings mean some specific thing, or that we can make predictions about the future. Indeed, it is the opposite of taking the bait. It is defeating the debater by refusing to go on the defensive.

Pros of agreeing with the uncertain potential

  • It provides a functional exposure (well, maybe that could occur, I don’t know) while interfering in ability to complete rituals (it leaves the verdict on thoughts intentionally incomplete).
  • It is honest (any statement that starts with “maybe” is technically true however improbable, as in “maybe I will be abducted by aliens tonight” vs. “it is proven fact that I will not be abducted by aliens tonight”)
  • It can develop into a healthy habit of openness to uncertainty and mindful awareness.

Cons of agreeing with the uncertain potential:

  • It can increase anxiety because of the absence of reassurance and the assessment that fears can come true.
  • It does get involved in the content of the thought, which can be a slippery slope to mental rituals
  • It requires significant effort to resist following it up with compulsions and can be exhausting

Agreeing affirmatively

You may find all sorts of books and blogs alike that recommend simply agreeing with the thought. Done effectively, this can be a way of basically pulling a thought through the mind that would otherwise be stuck. It says, “Alright, fine, it’s all true, let’s get on with it already.” Or you might agree more emphatically, thus allowing yourself to become so affected that you experience strong urges to do compulsions, which you can then practice resisting. Every ERP is a learning opportunity.

Note however that in this discussion I am primarily talking about how to respond to thoughts moment to moment. This is different from how to respond to thoughts in the course of a specific exposure exercise that you may be working on in your treatment. Some forms of imaginal exposure, for example, may promote the use of saying that an unwanted thought is “true” and really hanging on to this as a strategy for increasing anxiety to a level that can produce therapeutic benefits. But in the day-to-day, the habit of affirming the content of thoughts can also be problematic because, quite frankly, there’s more to life than ERP.

Pros of agreeing with thoughts:

  • It provides an immediate exposure to the feelings associated with the content (as in, when I say the words “I will kill my baby”, I feel disgust and I can then do exposure to that feeling, which is the feeling I most often have trouble resisting compulsions around).
  • It is a way to outdo the OCD and beat it at its own game, which can be confidence-building and even humorous.
  • It eliminates the need for debate over the meaning of the thoughts by assigning it a blunt meaning without analysis.

Cons of agreeing with thoughts:

  • It isn’t technically honest (you could kill your baby, but you can’t know that you will).
  • It can become a form of compulsive checking (did I like it when I said it?) which can easily spin out of control.
  • It can be used as a form of compulsive self-punishment.
  • It gets involved in the thought content and it may cause panic or trauma responses in some susceptible people

Hey, over here! A word about distraction

Many readers may have heard that distraction is a good thing because it takes your mind off of the OCD. Or you may have a heard that it’s a bad thing because it functions as compulsive avoidance of your obsessions, ultimately making them worse. Both of these things can be true or untrue depending on intention. Distraction is just anything that interferes in your ability to give full attention to anything else. To use distraction as an intervention with unwanted thoughts in OCD, the benefits and drawbacks are rooted in whatever message the brain is likely to receive from the shift in attention. Is the brain being informed that thoughts are unimportant such that attention can be lifted from them with ease and dropped on something else? Or is the brain going to get the message that thoughts are so terribly important, we can’t bare to be in their presence for even a moment without distraction?

Bad distraction

In the course of exposure, you become very uncomfortable. To get away from the uncomfortable feeling, you might distract yourself with a video game you’ve played a thousand times that helps you shut off your thoughts. This is what I would call “bad distraction” because it sabotages the exposure therapy (by not allowing you to feel the discomfort and learn from it) and because the attention is being placed in a dead zone and not on something that promotes growth or represents a meaningful value. It is escape. Now let me be clear, escape is not the enemy all the time. We all have a right to check out from time to time. But in the midst of an exposure is not a helpful time for this.

Better distraction

Imagine you’ve just been triggered and the way you are accustomed to responding to triggers is to engage in an elaborate mental ritual that involves reviewing all of your memories associated with the trigger, imagining fictional scenarios where you respond a specific way to your trigger, chanting thoughts that neutralize your fears, or any or all of the above. In other words, the train of your mind is headed to Compulsion Station and you need to get off. Though it is widely agreed that “thought stopping” or trying not to have or not have certain thoughts, is ineffective, derailing a mental ritual is fair game. Ritual-stopping is not thought-stopping.

I sometimes refer to this as running interference. If you can’t think, you can’t complete a mental ritual, and if you abandon a mental ritual before it produces any satisfaction, you’re doing ERP. You’ll know it’s ERP because it will feel flippant or irresponsible to suddenly stop devoting your attention to the ritual and devote it to something else. To effectively drive a wedge between you and the ritual, you can push the mind to attend to something that requires focus and is incompatible with ritualizing. A good example is to try to remember the sound of a 56k modem connecting to the internet (a what? said the reader born in the 1990s). Or, feel free to recollect the lyrics to Peter Cetera’s The Glory of Love, which is infinitely worse than Rickrolling yourself (look it up). The point is, you can’t focus on these things and complete your rituals at the same time, and, once disengaged from the ritual, you can work on resting your attention more mindfully on the present moment. I call this “better” distraction, rather than “best” because this kind of distraction has no real value of its own and is just a tool for disengaging from rituals. Used excessively, it opens a susceptible thinker up to potentially using this tool as a compulsion itself.

Good distraction

If we understand distraction as something that is interfering in focus, “good” distraction is probably not even a kind of distraction so much as a kind of self-direction. In other words, running to something of value instead of running from something scary. One of the greatest challenges obsessive thinkers have is coping with unstructured time. Without a specific present to return to, mindfully stepping back from obsessions doesn’t make much sense. A highly trained and skilled meditator may be able to rest his attention on the feeling of his feet on the ground, but most people find this uninspiring.

So good distraction is filling your life (not to the brim) with things that you value already or have the potential to add value. Good examples are hobbies that leave products behind, such as writing music, painting, or building something. Non-compulsive cleaning or exercising can be good, but they may lack the mental invitation to truly latch the attention securely. Watching movies and television can be a great distraction if the thing being watched is something that will feed your artistic heart, teach you something, or at least give you the opportunity to float a fan theory by your friends. Mindless reruns of shows that provide you nothing but noise and leave you feeling empty inside will not serve this function. So best distraction is when we are mindful of our OCD enough to know that it could use some competition and then to self-compassionately provide ourselves with something worth attending to.

Don’t be perfect

Be beautifully imperfect. It’s harder but it pays better. There is no one right way to respond to thoughts. And if there were, to use it every time would quickly turn it into another “wrong” way, a compulsion. The endgame here is being able to see thoughts as thoughts, not threats. You can entertain them, but only if you wish to entertain. You can expose to them, but only if you want to do the work in that moment. You don’t always have to. You can allow and accept them exactly as they are, but only if you can do so without bullying yourself (“Accept! Accept!!”). If you carry with you a big toolbox for OCD, you can develop the self-confidence needed to reach in there with eyes closed, pull out whatever you connect with in that moment, and use it to navigate OCD in that moment alone. Mastery over OCD is not about being right all the time. It’s about versatility.

Jon Hershfield, MFT is a psychotherapist in private practice licensed in Maryland and California, and director of The OCD and Anxiety Center of Greater Baltimore.  Follow him on Twitter and Facebook

The post How to Respond to Unwanted Thoughts appeared first on The OCD and Anxiety Center of Greater Baltimore - Director, Jon Hershfield, MFT.

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In 2015 I moved back to my hometown in northern Maryland. It’s been an incredible journey. Naturally, there was some uncertainty to contend with, such as how or when new local clients would come my way. But it’s been less than a year since I went from left to right coast and the Jon Hershfield, MFT project has become The OCD and Anxiety Center of Greater Baltimore. I am so pleased to announce the addition of Brenda Kijesky, LGMFT, to what is now a team of OCD treatment providers using mindfulness and cognitive behavioral therapy to help OCD sufferers master their disorder.

Who?

Brenda is a Licensed Graduate Marriage and Family Therapist in the state of Maryland with experience using cognitive-behavioral therapy and mindfulness in conjunction with family systems therapeutic models in treating anxiety disorders, mood disorders, and trauma in children and adults, as well as treating general family dysfunction. Brenda believes that a relationship built on mutual respect and trust is the foundation for successful therapy. She approaches therapy with warmth and compassion, tempered with tough-love. Brenda believes that asking for help shows bravery and resilience and that just walking through the door to therapy indicates that a client has the capacity for change.

Before joining The OCD and Anxiety Center of Greater Baltimore, Brenda provided therapy to children in residential treatment who experienced acute and chronic mental, emotional, and behavioral issues, which frequently were accompanied by histories of trauma, abuse, and neglect. She also has experience providing therapy in community mental health clinics in both inner city and suburban settings. Prior to her career in mental health, Brenda worked for 13 years in the marketing field. When she no longer found her marketing career fulfilling, Brenda returned to school to pursue a career in therapy. Brenda holds an MS in Clinical and Counseling Psychology from Chestnut Hill College in Philadelphia, PA. She also holds an MBA in Marketing from LaSalle University’s School of Business and a BA in Journalism/Public Relations from Temple University, both in Philadelphia, PA. Originally from the Philadelphia area, Brenda relocated to Baltimore in 2009.

Training Brenda to use her CBT background in anxiety and trauma as a platform upon which to build a specialty in obsessive compulsive disorder has been really easy. Brenda has an intelligence and wit that will make new clients at our center immediately feel supported and motivated to stand up to OCD. She will be providing reduced-fee services and spearheading our forthcoming Saturday OCD group. So welcome, Brenda, and welcome everyone to The OCD and Anxiety Center of Greater Baltimore – mindfulness and cognitive behavioral therapy for individuals and families affected by OCD.

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