This week I will be blogging about how to cope with OCD. Each day I will share tools that support the cognitive behavioral approach of ERP (exposure and response prevention) derived from all the different approaches I incorporate when I treat OCD in children, adolescents and adults including Cognitive Behavioral, Mindfulnes, Somatic, Psychodynamic and Gestalt Therapy. So if you’ve had CBT and it hasn’t completely helped you or you can’t bear it, hopefully there will be something of use to you here.
Let’s start with an overview:
Obsessive Compulsive Disorder has two components. Obsessions are unwanted, distressing thoughts, senses, impulses or images that feel uncontrollable, irrational and intrusive. Compulsions are the strategies people use to reduce or undo the anxiety caused by these thoughts. Compulsions can be performed externally (like handwashing or checking multiple times if you locked a door )- or internally (also known as “mental rituals” ) where the person reviews thoughts over and over in their mind, or reassures themselves that something bad didn’t happen- in order to reduce or undo the anxiety caused by these thoughts.
A classic example of OCD is where someone fears they have been or may become contaminated by certain things in their environment and because they cannot bear these anxious thoughts (obsessions) – they may wash their hands repetitively throughout the day (compulsion) to prevent or rid themselves of this fear.
The problem with the OCD cycle is that although compulsions initially serve to reduce a person’s anxieties stemming from their obsessions, in the long run – this cycle becomes addictive and the person often cannot get out of it. Compulsions can take hours upon hours and impair one’s ability to cope, work or relate to others. Compulsions also feed obsessions because they reinforce the person’s belief that they need to avoid feelings of uncertainty, discomfort or anxiety in order to feel safe.
OCD can be mild or extremely distressing and debilitating. It tends to get exacerbated around stressful times in a person’s life such as following a job loss or a life transition.
Obsessive thoughts tend to manifest in different fear categories for different people which include but are not limited to fear of self harm (eg being around knives, potential weapons), fear of harming another, fear of contamination, fears about sexual or violent thoughts (eg worries that you are a child molester, a latent criminal etc.), scrupulosity (which often involves fears about punishment from God) and perfectionism.
A number of other issues are considered OC spectrum disorders because they share similar features with OCD but differ in their particular thought and behavior patterns and require different treatments. OC spectrum disorders include trichotillomania (hair pulling), skin picking, body dysmorphic disorder (preoccupation with thinking something is wrong with your body) and hypochondriasis.
OCD is often confused with OCPD (Obsessive Compulsive Personality Disorder) which is more of a pervasive personality style involving rigidity and perfectionism that is less about rituals and more about maintaining control over one’s life. People with OCPD may be overly concerned with rules and details or ethics and morality and may insist that things must be done a certain way. There can be an overlap between these two diagnoses which can take some sorting out of what’s what.
The treatment of choice for OCD thus far (because it has the most research behind it) has been a form of cognitive behavior therapy called ERP- Exposure and Response Prevention in which a person is exposed to the things he/ she is most afraid of (his feared thoughts) and then willingly prevented from engaging in their usual response (the compulsion).
The rationale behind exposure therapy is the importance of helping the person come to accept that uncertainty is a part of life and helping them let go of the need for certainty. Cognitive skills- which are skills to help clients challenge their unhelpful thoughts that may be particular to OCD- are taught to help ready a person for the main course of the treatment (the exposure).
The exposure component is implemented gradually so that the client can slowly build up to tackling higher levels of anxiety after seeing they can handle lower levels first. Exposure sessions typically last for 90 minutes or until the person’s anxiety begins to decrease. The explanation for why people’s symptoms improve during exposure is “habituation” which is that over time- the person develops a tolerance for facing these difficult thoughts/ feelings evidenced by the decrease usually seen in their anxiety levels during exposure sessions.
ERP may sound a bit ridiculous when you first hear about it. “Okay.. you’re scared of being contaminated, so let’s go have you contaminate yourself right now” You’re wondering – as I often do- why would anyone agree to do THAT!? And why would anyone sign up to see a therapist to have them do that when they can do it themselves?! Because there is a lot of evidence and success behind this approach and it has been shown to create changes in the brain as much as medication can. It works- for many people.
The flip side though is that according to the research 1 out of 4 people refuse to do exposure and response prevention. I practice ERP with those clients who are able to come in and just dive right into the ERP but I find that many of the people I treat who suffer from OCD feel too frightened initially to begin with ERP. In these cases, we agree to engage in a longer treatment usually with the goal of doing exposure when they feel more ready and willing.
There are many hypotheses as to why people drop out of exposure treatment. Researchers are currently working on developing a greater understanding of/ strategies for better engagement in ERP. One current strategy is motivational interviewing which involves helping people explore their resistance and enhance their motivation levels to go forward. I have some of my own strategies and theories about what works in helping people feel more ready and supported to begin exposure and I will share some of these this with you this week along with some of the standard tools.
Brain Lock: A useful mindfulness tool for OCD and life in general
There are many “tools” that can be helpful for facing OCD. (I use the word “facing” because when you practice mindfulness with your feelings it involves learning to befriend rather than fight that which that comes up inside us ). One tool that I find very useful was conceptualized by Jeffrey Schwartz in his book Brain Lock. Brain Lock outlines 4 steps for healing OCD. I think of these steps as “tools for creating a life around and in spite of OCD”- until OCD eventually lets go of its grip… or really- until YOU let go of your grip on IT and soften your reactions to your distressing thoughts.
Here is a brief overview of how to apply the 4 steps of Brain Lock to an OCD episode with my a few of my own understandings thrown in:
1) Relabel: When you feel an obsessive thought coming on, you acknowledge what is happening by naming or labeling the thought in an effort to see it with more objectivity as opposed to getting sucked into its message. For example, if you start obsessing that you’re not sure if you locked the door and feel yourself wanting to check it again, you would relabel by saying “I am having the thought that I didn’t lock the door” rather than buying into the immediacy of “I didn’t lock the door” and taking the thought for what it claims to be… something you MUST respond to right now.
In life, some of us jump and react very quickly or impulsively to situations, not always taking the space to breathe and take a step back to say “hey what is this thing I’m so fast to react to?” Consider if you have already exercised this reflective muscle before in your life for example- when you wanted to eat a piece of cake but took a step back to reconsider that idea/ impulse. That’s relabeling or getting perspective and saying “wait a minute? Do I really want to hit this guy who just cut me off on the road? Where will this get me?!”
Relabelling puts some space/ distance between yourself and your thought and gets you more in touch with yourself as the observer of your thoughts so you get to be in charge of deciding whether to listen to the content of these thoughts rather than being victimized by them. Again this takes a lot of practice and repetition as any very stubborn pattern does. Another word for relabelling is “defusion” in Acceptance and Commitment Therapy (ACT). For more practice with this skill see the ACT skills book “Get Out Of Your Mind and Into Your Life” http://www.amazon.com/Get-Your-Mind-Into-Life/dp/1572244259 by Steven Hayes and Spencer Smith, which provides techniques for defusing from painful thoughts (not specifically OCD, but very useful for it).
2) Reattribute: This step helps with the “why” question that comes up for many people with OCD. “ But why am I having these thoughts?!… maybe I AM a bad person… maybe it’s because I AM gay that I have fears about it..?” etc… Instead of buying into the thought’s message and doubting or blaming yourself, you learn to reassign the blame to your brain saying “it’s not me.. it’s my OCD that’s driving these thoughts” or “it’s a false message that my brain creates and I need to learn to ignore it over time…” . (This is similar to the AA philosophy which views drinking as a disease rather than one’s fault). This technique is just like what is done in meditation when you remind yourself over and over “this is just a thought” reminding yourself that “this is what the mind does. It produces lots of thoughts”.
A note of caution: know that when you first begin this process it will probably not feel like your obsession is JUST a thought. You might find yourself getting very angry when you say that at first…. “what do you mean JUST a thought!? It’s a thought that is destroying my life..!” Labelling the thought in less dramatic terms is a way of reducing the charge of the thoughts but initially it can feel like a minimization or even an expectation that you SHOULD be able to accept this is JUST a thought- which can lead to more self blame ie “why can’t I see it as JUST a thought?!”
So, it might help you to work on developing some compassion and patience for yourself when you first begin this process. OCD takes time to treat. It will go in time, but first work on easing yourself into accepting things as they are at this moment while reminding yourself “okay.. it doesn’t feel like JUST a thought but I am working on it- so that in time I will experience it that way. Maybe I can begin to see just how reactive I get to that thought and re-train my brain as I might when I see a person I really don’t like..”
In time and with practice you will be able to lessen your reaction to your thoughts as people with other compulsions have learned to. Or, you will learn to stop tuning into that frequency and become less interested in it, the more you live your life around it. The reatrributing step can also help you begin to work on skills for tolerating the presence of your distressing thoughts and letting it be there without feeling compelled to make it go away or engage it. This is very hard at first, but you will see progress over time. You also need to expect that you WILL get pulled in often intially and for some time because those particular thoughts have a lot of power over you right now (More on that another day).
3) Refocus– Here you learn to work around your thoughts as they occur, almost as if you’re a parent who has been unable to reason with your child who won’t stop their VERY loud tantruming and crying. Yelling at them or trying to convince them to cut it out often does not make them stop. Though you may not react as powerfully to the screaming child as you would to an obsessive thought that you could harm a loved one if you don’t check if you turned off the oven- you try to let the thought be there rather than fighting it or engaging with it and you go and do something else because what can you do ? it’s there and denying that it is or fighting won’t make it go away. You re-engage and in time you may not notice its presence or it may fade and lessen in its intensity. See Brain Lock or Jonathan Abramowitz’s book “Getting Over OCD” http://www.amazon.com/Getting-Over-OCD-Workbook-Self-Help/dp/1593859996 for details on how to delay giving into rituals.
Refocusing is difficult and it may even mean that while you are doing that something else you allow OCD to “come and go…” by narrating and witnessing your experience as it happens and learning to be patient with yourself. You might say “that thought of harm is coming and going and I’m going to have a life anyway… people live their lives in spite of their chronic pain, loss and other distressing experiences and I am right now going to live despite my thoughts.. they are not me.. and I am learning to tune them out and it takes time. “ Oh and one last part! Credit yourself for doing this hard work “ good for me that I’m working on this..” Your struggle with OCD is just as real and as difficult as dealing with chronic pain or other pains we humans live with so don’t let anyone who minimizes it (because they lack understaning) make you feel unentitled to your pain.
As for which activities are good choices to shift to- reading is not always the best choice for some because it requires concentration that may be hard to attain in that moment when your mind already feels overly taxed. Something more active might be better such as painting, boating, playing a sport, walking and seeing if you can notice particular things in nature, an online game or something that can compete with your thoughts and might help you touch down into your spirit rather than just your mind.
Begin by trying to create a delay between wanting to act on the thought “I need to wash my hands!“ (like “I need a cigarette!’) and acting on the urge. The goal in the short run is not to make the thought go away. (Of course you want it to..it upsets you, but wishing and then checking “is is still there? “ only makes it more painful than lessening your reactivity to it) . You may even need someone in your life to gently encourage you to shift to another thing or you can imagine you’re taking your own hand and cajoling yourself “come on.. that’s enough right now, let’s try something else.”
4) Revalue: This is really about giving less value to OCD and more value to your life. Acknowledging that you don’t have to stop living because of a distressing thought. It’s the result of the prior steps.
Personally I condense these steps into two because it feels easier for people to just remember.. “oh that’s my ocd.. okay. I’m going to try not to go down that path right now by encouraging myself to shift to something I’d rather do even if it’s still going to hang out in the background..”
Criticisms of Brain Lock
Brain Lock has been criticized for its lack of adequate empirical evidence and its lack of efficacy in severe OCD cases. Personally, I’m not a big stickler for left brain science (though I use ERP) because I’m also a big proponent of trusting your experiences and your intuition (which I believe is part of treating OCD). When I see clients getting better and reporting changes from using a particular method – it’s good enough for me to use again. Brain Lock is intuitive. It is mindfulness applied to OCD and mindfulness changes brains when practiced correctly.
I’ve treated many people who have had success with the brain lock approach and it has helped them cultivate awareness not just of their obsessive thoughts but of their many other thoughts and mental patterns. A mindful approach helps people recognize that they are much larger than their particular wacky thoughts that are part of having a human mind (though some of us may not admit readily to them!). It puts people in touch with the “impartial witness” to their experiences.
Critics of brainlock, who are often supporters of ERP, also argue that brain lock encourages “distraction” or avoidance and therefore does not enable people to habituate to their OCD fears the way exposure does. Personally- I have seen many different approaches work for different people. There is no one size fits all approach and if someone cannot tolerate exposure- and brain lock helps them- that’s great.
I think it’s important to differentiate between when brain lock is being used as an avoidance to accepting the uncertainty (that is necessary to face in OCD) as opposed to when it is being used as a tool to retrain the brain because the person is either not yet ready for the intensity of exposure, has completed exposure but is still struggling or finds lengthy exposures too terrifying or even unnecessary for their healing.
As with practicing meditation, there are many ways to approach our experiences ( OCD included) and each can retrain the brain in different ways. In meditation, sometimes you narrow your focus on your breath (as with OCD- you narrow your focus by staying with your worst fears in an exposure session ).
At other times it may be helpful to pull back and widen your lens as with brainlock by taking stock of the entire landscape of your experience such as when dealing mindfully with chronic pain and doing a body scan meditation. With body scans you DO first acknowledge (relabel) your experience- ie that you have a headache (you’re not ignoring it or minimizing it) but then you skillfully choose to shift to other areas of your body that don’t have pain.
These practices reinforce the vastness of who you are and your ability to contain ALL of your experiences. They also connect with the fact that YOU (not your OCD) have the POWER (maybe not yet but you will) to choose another experience that feels better. Learning to shift out of the stuckness ( a definite hallmark of OCD) teaches this skill of flexibility which is essential for all healthy mental functioning.
For more tools and tips on your road to recovery, check back with my blog this week.
And, if you’re interested in learning new and traditional tools for coping with OCD, I will be starting a group in Manhattan in the fall of 2012. Feel free to contact me for more information.