Dealing with Feared Consequences When they Happen: The Impossibility of Coming Out in Advance

A post by Pure O Canuck got me thinking when she about her relationship OCD(ROCD) and homosexuality OCD(HOCD),

When does this horrible urge/need to find the answer end? And why does it seem like others have found the answer and I can't? It seems like others are living happily ever after. Can I say that I feel that way about my relationship at the moment? Definitely not. (Spend too much time on that and the ROCD starts up - but that's for another post.)

This desire to live happily ever after is seductive for all humans, and when you have OCD, there can be a gnawing, erosive need to figure out if you actually are living happily, or whether you have made a huge mistake in who you choose to be with by compulsively analyzing or avoiding all triggers of the fears. I read lots of "coming out" stories in college(which is one of Pure O Canuck's exposures right now), and I longed for the click, the final puzzle piece going into place, the revelation or vision that these stories seemed to offer. But I am realizing that the OCD is latching onto the metaphor of "coming out" as a form of absolute certainty, which in actuality it is not, and OCD is very opportunistic and picks up on other images like being "in denial about being gay." As Pure O Canuck says,

I know that I am not going to get an absolute, certain answer to these questions. (I don't quite understand why - it seems like others have it. But I guess that's just a momentary feeling and it will come and go.)

It's hard to accept that other people seem to have absolute certainty, and there's a longing to have some of that elixir, but in reality, people without OCD may simply be able to move on in spite of some uncertainty, rather than seeking to eradicate every last remnant. Others were indeed in denial about being gay because of strong cultural and religious pressure and condemnation, but eventually reached a point where they came to accept who they were, in spite of trepidation or fear, and often sound at peace, but this isn't the same thing as absolute certainty. OCD never grants peace in the long term. If I feed my OCD with figuring out, analyzing and avoidance, even if one obsession recedes, another one will appear.

My therapist likes to say, "If your feared consequence happens, you'll deal with it then. You don't need to know the answers to your OCD questions right now." That's the basic uncertainty--the women in some of these coming out stories didn't know that they would suddenly fall in love with a woman--but if they didn't have OCD, they dealt with it when it happened, not in beforehand rumination.

I did the exposure of marrying my boyfriend, my now husband, in spite of agonizing whether I was really lesbian, and might never truly be happy, and over the years have grown to love my husband more and more, but I had to deal with a burst of anxiety about whether I loved him "enough" and when our 10th anniversary came, and we planned to renew our vows, I had a panic attack about whether I really could say "until death do us part"(which totally misses the point that I already had taken that vow the first time around!!) OCD narrows our vision, and allows no possibility of grace or peace.

Sensitized for Instant Response: Ruining the Day

This week I've been getting stuck in fear of ruining my day, that doing something "wrong" will contaminate the rest of the day. I'm so used to making up rules for myself as to what constitutes a good day, and the OCD has me sensitized to any thoughts of "you did that wrong" or "you should've done something else," that before I even realize it, I'm reacting to the thought, wanting to eradicate it.

When I think those kinds of thoughts, I tend to take them at face value, as if they were true and credible, and with power to change the entire quality of a day. The closest metaphor is contamination. One of my feared consequences is that if I choose an imperfect action, it will spread to the rest of the day, and can't be cleaned up. My compulsion is to undo the thoughts of having messed up by either ruminating on them, analyzing them, or going into habitual websearching as a distraction. And then, ironically, OCD causes the very thing I fear--this compulsing ripples through the day and takes up my time.

I asked my husband yesterday if he thinks this way, and he said no. He might do something that ends up being a waste of time, but then he moves on to something else. He doesn't have fears that if he somehow goes awry, it will haunt him. For me, it's very basic stuff, for which there is no handbook or optimal schedule. When to take a shower. When to eat lunch. When to take a walk. When to run errands.

I have a big fear of wasting time. If I have errands to run, I get mired in figuring out how to do enough at a time so I don't "waste time." The fact is that sometimes we waste time. It's as if the OCD decrees that I live in a universe where I don't ever make a mistake or take up time doing the activities of daily living, and the insidious part is that for a long time I truly believed that I could find certainty as to what I should be doing in any given moment.

In the past, I also feared ruining a day by having intrusive scary and anxious thoughts. I've gotten better at recognizing them as part of my OCD, and not getting into a power struggle with them, and eroding all possibility of being present in my own life, but the thoughts of doing things perfectly slip in under the radar, and I do get into a battle with them. I see more exposures in my future, choosing things to do in a day, and doing them, and facing the fear. I'm edging towards this, in spite of my aversion.

Intrusive Thoughts and the Search for the Answer: Part 2

As I said in Part I, the intrusive thoughts that seemingly took me over as a girl, became a fact of my history that I spent a lot of time trying to figure out. It was a reference point, a mystery, and an indictment in my mind. How could I say I was a feminist? How could I say I cared about women? How could I be a good person? Surely these thoughts and images of violence invalidated anything I might believe about the value of women. In my 30's I started seeing a therapist for depression and anxiety, and worked up the courage to tell her about the thoughts. She did something that many therapists do: she gave her interpretation. Interpretations can yield useful insight if they're not about obsessive thoughts. She said that it sounded like I was angry at my mother.

Although it was reassuring that she didn't think I was a bad person for having the thoughts, the idea that such violence in my mind's imagery was somehow symbolizing anger at my mother scared me. What kind of daughter was I? How could I ever survive such awful anger? Interpretations add fuel to the OCD fire. Each new interpretation brings its own set of things to figure out.

It is the painful irony of OCD that intrusive thoughts often strike at the very things that are most precious to us. A truly pious person has blasphemous thoughts, a gentle soul has violent thoughts, a feminist has thoughts of violent pornography. The other brutal irony of OCD is that even when books or websites that clearly describe the experience of intrusive thoughts, and the fact that they say nothing about you as a person, the OCD latches onto this and sets off a cascade of figuring out: "Do I really enjoy these thoughts? Do I really have OCD? How can I know if the thoughts are actually intrusive?" Or if you see a therapist, you can fall into the "What if I'm not truly expressing my thoughts clearly, so the therapist can't see how truly bad and twisted I am? What if I am deluding them?"

It helped immensely when I found an exposure therapist, and he knew that this cascade would appear--he would say, "I bet you are trying to figure out if your thoughts are an exception to the rule, and the OCD is getting louder and louder as we sit here--am I right?" Making the pattern explicit helped me to know it's sneaky insidious ways, and the insatiable desire to prove once for all that I am ok, not bad, not unredeemable.

Intrusive Thoughts and the Fear of Being Unredeemable

Rosalie Stanton recently found my blog and shared a post she wrote about her struggle with intrusive thoughts.

I had no idea my obsessions were perfectly in-keeping with my particular case of OCD until recently. I'm not certain if it helps others afflicted with OCD, but the knowledge that I was NORMAL probably saved my life. For as miserable as I was, thinking I was wrong and twisted and evil, finding out that my disease had a name and there was nothing I could do to prevent it, nothing I was at fault for thinking, was the biggest blessing I've ever received.

The pain of feeling wrong and twisted and evil is something I know as well. When I was 9 or 10 years old, I started having thoughts that most adults would find scary, violent, disturbing, let alone a child. It was as if they were injected into my mind, just suddenly there, in an occupation, a siege. I wondered why I couldn't make them stop. I began to enter the world of my thoughts in a set way, in a ritualistic sequence, as if I was standing in front of a mirror, looking at my face, and crossing through into a world of torture of women, an observer of it all.

How I came back out each time, I don't recall, but I remember feeling defeated when the thoughts came back again. The images spun themselves into a series of stories, expanding seemingly endless to my young mind. It was as if they wrote themselves. They were unfamiliar, alien. Even now, I can't comprehend where they came from. They so crowded my mind, that one afternoon, I asked a friend to play out part of the story where doctors kept women captive. Her look of confusion combined with a stabbing sense of shame, but also gave me a little room, to feel grounded in the actual world, not in my head.

She was completely uninterested in cooperating, and from the day onward the thoughts did not return in that form. I was amazed that I no longer was sucked into the narrative of fear and violence. The thoughts did remain as a memory, as something I wondered about, as a part of my history.

In college, I participated in a survey about women's sexual fantasies, and I was stricken with fear that my old thoughts were a fantasy, that they were something I wanted to think about, something I enjoyed. Filling out the survey filled me with dread about what my thoughts meant. Then I went to a presentation about the destructiveness of hardcore pornography, with a series of slides of some of the most violent images in magazines, and it was as if the images from my past were there right in front of me. I was in a state of anxiety and fearfulness. The slides repulsed me, and yet the old images from my mind were of the same substance. I was startled by the resemblance, and even more troubled about what this meant about me as a person.

I started to worry that somehow I had been subjected to pornographic magazines as a girl, but couldn't remember it. Or maybe I had been sexually abused. Or maybe I was just bad. That all my interest in helping women, the classes I took on women's history, my compassion for suffering, was all a lie and in fact I was twisted, that all girls were twisted in some way. I spent a lot of time in my head, trying to figure out the nature of my soul, the origin of the images, and the new set of horrors that the pornographic slides had introduced into my head, and desperately wanting to make them go away.

To be continued in another post.

Field Guide to OCD: Feeling on Trial

I feel like I'm on trial by OCD. This is one of the clues to recognizing being in the OCD. The OCD thrusts the burden of proof on me. I must prove all things beyond any reasonable doubt, which of course, OCD doesn't ever recognize. When I started Exposure Therapy, my OCD had a lot of power and credibility.

Right now, I am on the computer, after being on Skype. I called at 8:00 am, the time I used to start work when I was employed, and once I got off the phone, I was back in my old work pattern of compulsion, which was to stay on the computer, in a kind of trance, because anything else I might do could be the "wrong" thing, and I would be in for harsh cross-examination from my OCD thinking. I'm doing my mental rituals of checking of what time it is, how many minutes have passed, diverted into the "why am I doing this? What is wrong with me?" line of questioning, followed by, "you can't undo this. you've ruined your day, you can't salvage it. you suck."

This adversarial mode adds more fuel to the OCD fire. And OCD talks a confident way, a dictatorial, demanding way that is intimidating, and uses a kind of brute force, saying the same thing over and over, louder and louder. What if! What if! What if!

A cross-examination complete with, "Just answer the question. Don't explain. Just answer yes or no. Strike everything else from the record." What if I am fucking up my life? What if I am making a horrible mistake? What if I really am bad? What if I don't really deserve any compassion? What if I am wasting my life and this is unforgiveable? What if I am beyond redemption?

Often my own thinking seems pallid and inconsequential, signifiying nothing, powerless. But it's my own thinking that allowed me to get into treatment, and start doing things with my life, and learn to have compassion for myself. This is the act of faith, to trust the quiet still voice, without knowing for sure if it really is my own thinking--the OCD chips away at that too, demanding I know for certain if I'm thinking for myself or if it's OCD.

This is crazymaking stuff. Depending on the context, the my current line of questioning can completely contradict another line of questioning from just a second before. From "Don't trust your thinking" to "What's wrong with you that you don't trust your own thinking?" to "Ok. But are you sure this is your own thinking and not the OCD?"

What is the fruit of your OCD? What kind of fruit does it bear? Does it bring peace or joy or meaning to your life? If I am brave and take a minute to observe, I can see the destruction it wreaks, the poisonous fruit OCD bears, the mess my life became when I was totally in grips of it. OCD certainly promises peace, and promises if I just stay at the computer and answer all the questions, that I will avoid the turmoil of getting up, and facing my day in a backlash of obsessiveness, but I know from experience, if I stay on the computer a few more hours, until my back hurts, and I've thoroughly exhausted myself and my mood has deteriorated, that any peace I get is an illusion.

OCD and Emetophobia: Fear of Throwing Up

Emetophobia is part of my health anxiety history. When I was 11, I got sick to my stomach, and my mother gave me some sort of medicine from a cold spoon, and I promptly threw it up. Maybe I wouldn't have reacted as strongly, if she hadn't given me another spoon of medicine a few minutes later, and of course, back up it came. I vowed from that moment that I would never throw up again. I kept my vow for over 12 years, but this vow came with a cost, as it was intertwined with my OCD. If I felt the slightest twinge of stomach discomfort or nausea, I would keep checking the sensations, trying to figure them out, diagnose them, and this would make my stomach even more tense and uncomfortable. Then I would start drinking water, with the idea that I could dilute the toxins with fluid. I'd be up all night, drinking glasses of water and unable to sleep because of my hypervigilance.

Finally, I ate something that was truly toxic, and my body wanted it out, and I threw up at age 23. It sucked. But once it happened, it was over. The phobia is never "over"--it will expand to fit whatever room there is in your life. I feel sad when I read about people with emetophobia who restrict their lives more and more in order to avoid all possibility of getting sick, or of their kids getting sick. The difficult thing is that most people hate throwing up. It's easy for this phobia to slip under the radar, since it seems logical to avoid getting sick. But a phobia will impinge on valuable things in your life. No trips because you might catch something. No parties. No eating out. No leaving the house.

I could never have predicted what made me sick at age 23. This is the sucky thing about being human. We get sick. The world isn't a clean place. Exposure therapy for emetophobia isn't about making someone sick. This is the first thing people think of when imagining treatment. Exposure therapy is about doing those things you are avoiding because you *might* get sick, and not doing rituals like constant sanitizing and hand washing. If your first thought is, "Well, I'll never get treatment, because if I have to take the chance of throwing up, there is no way I will do that"--I encourage you to think about all you are losing to this fear. If you get sick, you will deal with it then. You are stronger than you think.

OCD Cartoon by John Spottswood Moore

Dr. Michael Jenike on the Yahoo OCD-Support Group mentioned this short animated video about OCD. I resonated with the spreading nature of the character's fears. I don't have contamination OCD, but the process of OCD thoughts multiplying was very familiar.

AIYH Sample from John Spottswood Moore on Vimeo.

My Experience with Exposure Therapy for Health Anxiety, OCD and Perfectionism on Health Place Radio

My radio interview about Exposure Therapy on HealthyPlace Mental Health Radio Show is up, so check it out.

Listen to the HealthyPlace Mental Health Radio Show

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Tune in for an interview on Exposure Therapy

Your one wild and precious life: OCD and Trusting Your Heart

My exposure this week has been to get into my studio first thing in the morning, rather than get on the computer. In the irony that is OCD, I love being in my studio, but the ritual of distracting myself on the internet has worn a groove in my brain, so I put off making art. I've been leaving a voicemail with my therapist once I get myself into the studio. My mornings have been a chant of "eat breakfast, go into studio, call Leonard" with varying amounts of squawking from the OCD, but I've made a lot of art, which is good, because starting next weekend I have 7 craft shows in 7 weekends!

My love of art gives me a lot of strength for fighting the OCD. When I make art, I am in the present moment, and I rely on my intuition, my eye, my hands, my heart. Yes, the OCD intrudes, with delaying my studio time, or getting stuck on what to make next, or not wanting to take a break because I might not get myself back to the studio. But the self I am when creating art, is the self that is whole, and strong, and wiser than my OCD.

It took a long time before I let myself be an artist. When you've had OCD as long as I have, it intertwined with so many aspects of my being, and with my troubled family. I assumed that if I liked doing something, that this was irrelevant. I've met others recovering from OCD with a similar sense, and who also, like me, felt lost when contemplating what they might like to do, rather than what the OCD wants. Combined with my perfectionism and wanting to do things right on the first try, and my fearful thoughts of worthlessness, it was a struggle to experiment and try things out, but I loved art, and this love gave me strength to persist in making it, even though I wasn't certain it was what I "should" be doing.

The OCD chimes in with "Are you sure you love art? Maybe you don't really. Maybe you can figure this out. Start assessing the quality of your passion. What if you really should be doing something else, like when you felt called to be a minister. Maybe God is angry with your decision to be an artist." I did two semesters of seminary in a quest to banish the persistent thought that God wanted me to be a minister, in spite of my lack of any real desire to be one. I feel closest to God when I am creating art. My leap of faith is to trust my experience. This is akin to standing too close to the edge of a steep path up a cliff, and feeling woozy, but this is my one life, and OCD is lying when it promises complete safety.

I'd love to hear your story of what you love. Take your best guess, the smallest inkling if that's all you have. Think of it as an exposure.

Here are some lines from a poem, "The Summer Day," by Mary Oliver, that speak to me, and hopefully to you:

I don't know exactly what a prayer is.
I do know how to pay attention, how to fall down
into the grass, how to kneel down in the grass,
how to be idle and blessed, how to stroll through the fields,
which is what I have been doing all day.
Tell me, what else should I have done?
Doesn't everything die at last, and too soon?
Tell me, what is it you plan to do
with your one wild and precious life?

My Health Anxiety, High Cholesterol, Decisions and Curiosity

I had a doctor's appointment yesterday to check in about my blood pressure(the meds are working and my numbers are good) and my cholesterol(meh). My bad cholesterol, ldl, is at the borderline high number and I have a couple risk factors for heart disease, so my doctor suggested low dose of a statin drug.

I had a big obsessive compulsive crisis about statin drugs a year or two ago, with fear of side effects and misgivings about the number of drug company funded physicians developing guidelines for when to start statins. One thing that really sucks about health anxiety is that as I get older, things really do go wrong with my health, and navigating this is like having a map but no street signs in order to use it.

I saw Leonard, my therapist, today, and he asked what was important to me in this decision(not what the OCD decrees, ie. absolute omniscient foreknowledge). It's important to me to take care of myself. I don't want to have a heart attack. My desire to avoid making any decision is strong, but I know that this is not a way to take care of myself. There are definitely aspects of my diet that I can work on, which may help, but I'm already a vegetarian. My cholesterol was fabulous when I was vegan, but that was almost 10 years ago, and I maintained veganism through sheer OCD hyperfocus on proving I was a good person.

It still feels odd trusting my own judgment. My husband of his own volition looked at the Mayo Clinic site for me, and it doesn't sound like much has changed since my last desperate search for a definitive answer. I've been having impulses to do my own search(actually, searches. One search is never enough), but I know that leads to suffering. It comes down to a) I can't know right now if diet will be enough b)It's not possible to know in advance if I will have side effects from a statin.

My desire to step outside of history and see the future as to whether statins are indeed the best choice in lowering cholesterol and preventing heart disease, and it's a desire that can't be fulfilled. Leonard said to look at what is reality and what is fantasy. My fantasy is that I could start eating perfectly, and avoid all the turbulent anxieties about side effects and drug company dealings. Realistically, there are things I know I can do to improve my eating, but not perfection, and combining diet changes and medicine could work.

I've noticed a glimmer of curiosity about the medicine, rather than just anxiety. I've noticed I can get a lot more done when I'm curious, and willing to try things, and see how they turn out, rather than trying to predict the future. The anxiety still sucks, but the curiosity gives me hope. Leonard said if my OCD gets active during this process of dealing with my cholesterol, that we will work on it together, and that I don't have to let the OCD decide for me.

Tune into Healthy Place Mental Health Radio Show for an interview on OCD

I was honored to be asked to be a guest on Healthy Place's Mental Health Radio Show, this coming Wednesday, October 27th, 2010 at 8:30 pm Eastern Standard Time, to talk about my experience with having OCD and doing Exposure Therapy. Click Here to Listen.

It's also an Exposure for me to do the show, since it involves being on the telephone for 15 minutes! But I'm excited to share what has helped me in hopes that it will help others with OCD, particularly health anxiety, perfectionism and indecision.

I didn't know about Healthy Place Radio, and was interested to read their blurb:

. . .HealthyPlace is a privately held company started by people who are committed to the idea of reducing the stigma surrounding mental health and who feel that making authoritative mental health information available to the general public is a key part of achieving that goal. We are based in San Antonio, Texas. Our revenues are generated through the sale of advertising on the HealthyPlace website. HealthyPlace is not owned or directed by companies that sell any products or medications. None of the articles are written or influenced by companies advertising on our website. All advertisements and sponsorships are clearly identified and labeled. (you can read our editorial and advertising policies)

So be sure to tune in! The show should also be archived so you can listen to it after as well.

Related Post:
My Experience with Exposure Therapy on Healthy Place Radio

Health Anxiety and Hurtling into the Future

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When my health anxiety starts to be active, I notice a desperate desire in myself to know the future. This isn't the far away future that I seek, but the next minute or even the next second. It's like the dog in The Grinch who Stole Christmas--he is pulling a sleigh so loaded down with stolen gifts that it flips him to the back, and he is pulled skittering down the hill. I rush to meet the future, to know it, to know what will happen next with whatever symptom I am noticing, and in the process accelerate my fear and anxiety, toppling the full weight of my OCD into the next second and minute of my life.

The dialogue goes something like this(the OCD would be in all caps, boldface, but that's too hard to read, so just try to imagine it):

Me: I feel a tightness in my stomach.
OCD: What's wrong? You need to know now.
Me: It could be appendicitis. Will it get worse?
OCD: Figure it out NOW. If you don't whether or not it's going to get worse, you will be intolerably anxious.
Me: But maybe the pain will ease up.
OCD: You can't wait to find that out. You need to act now.
Me: I know if I go on Google, I will come out of a trance an hour later, and feel even worse, but yet, I feel that sinking in my chest, my face is hot, and I'm shaky, and maybe I'll be able to diagnose myself if I go on Google.
OCD: You need to see a doctor! If you don't, this means you are negligent and a bad person.
Me: I keep checking to see if it hurts. I prod my stomach, I don't do anything else but focus on the symptom. I feel like the whole situation is contaminated with my fear. I wish I could separate the anxiety from reality.
OCD: You can do that if you just keep checking.
Me: Maybe I'd feel better if I stopped checking, and let things settle down. Why can't I stop checking? I could fix everything if I stopped.
OCD: You can't do anything right! You need to know in advance if this is serious. If you go to the ER and you are just anxious again, they will mock you, and it just proves you are defective.
Me: I have some things I need to get done, and I'm not getting anything done. A trip to the ER is going to take all day. Where is my life going? I'm a mess.
OCD: Your stomach is feeling worse. Do something NOW!
Me: Listening to you is making my stomach tighten up. If I had to guess, I'd say that's what's happening. Yes, my belly might get worse, but I'll never have a chance to find out if I don't let it alone for awhile.
OCD: You can't leave it alone, or how will you fix this?
Me: I'm going to do my errands, and if I am seized with pain, I'll deal with it then.
OCD: But you need to know what is going to happen.
Me: I can't know what's going to happen in the next moment. You are asking me for the impossible. I can guess, and I might guess wrong, but this is the human condition.

Note all the crazymaking stuff going on with the OCD! What thoughts make you jump? For me, the insistent "need to know this NOW" is most likely to accelerate my anxiety.

Related Post:
Letting the Thoughts and Feelings Be There

Aubrey Lewis on the Nature of Obsessions: Depersonalization and Warding Off

In exploring the history of Exposure Therapy for OCD, I came across Aubrey Lewis, clinical director of the Maudsley Hospital in Britain. Many of subsequent developers of ERP were recruited or encouraged in their work by Lewis. In 1937 he wrote an article on the Problems of Obsessional Illness, where he describes some of the characteristics of obsessions. One definition he liked was by someone named Schneider:

. . .contents of consciousness which, when they occur, are accompanied by the experience of subjective compulsion, and which cannot be gotten rid of, though on quiet reflection they are recognized as senseless.

But Lewis notes that the recognition of the obsession as senseless is not essential, but the aspect of feeling one must resist the obsession is key--attempting to ward off painful and overwhelming obsessions, and paradoxically, ". . .the more overwhelming and painful the obsession, the more urgent and unsuccessful the devices to ward it off."

I recognize my experience in this! I also see the paradox that when I am at my most panicky, it is unlikely I'll get to the point of "quiet reflection", and even in 1937, Lewis recognized the limits of Cognitive Therapy with OCD, stating that, "Critical appraisal of the obsession, and recognition that it is absurd represents a defensive intellectual effort, intended to destroy it: it is not always present, nor is the obsessional idea necessarily absurd."

This is where Grayson's book Freedom From OCD really helped me in recognizing that some things I obsess about could actually happen, but that trying to get absolute certainty that they won't is impossible, and that I actually tolerate a lot of risk in the areas not affected by my obsessions, like when I worked in a hospital, and didn't worry about contamination.

Lewis describes the sense of having a part of one's self or mind working independently, not as an integrated part of oneself, and the desire to fight against it. Also, the acute awareness of "internal speech" and having words said outloud come back into one's head. Finally, he mentions depersonalization, where the patient,

. . .is commonly so far from feeling the master of his own thoughts that he has almost no personal or free share in them at all. . .

Lewis believes that depersonalization is a state that affects all thinking, not just parts of it, as in obsessions, but that they are similar. When I start web searching, I feel some of this exclusion from my own self. There are things I actually want to do with my life, and yet these recede in the face of an obsessional thought about needing to do things "perfectly" and subsequent compulsive trance-like searching of the internet. Lewis does not discuss treatment, and rambles a bit, but I appreciate his attention to what the experience of obsessing and compulsing is like.

What do you notice about your obsessional thoughts?

Avoidance

Again, Fellow OCD Sufferer has some thoughts that have me thinking, in response to my Anxiety in Disguise post. She talked about the difficulty of response prevention, and the fear of endless rumination and unease. That is the irony of the compulsions we use in OCD to damp down the anxiety--they become odious and cause their own suffering, while stealthily encouraging us to think that we couldn't function without our rituals.

And my life history colludes with this version of reality, because from a young age I used perfectionism as a way to make things right with the world, and allow the possibility I could exist on this planet. I barely registered in my parents' world. I was the invisible girl who still felt she took up too much space. When I delay writing something, because I fear going over it in my mind repeatedly, I am fearing the triggering of this compulsion, and OCD is more than glad to praise me for this. But what is even scarier, is contemplating writing something and sending it out into the world without going over it, and living with the fear that I've done it wrong, that I am inadequate and will be haunted by this distress forever.

And yet, I still get an initial moment of hopefulness when I start my compulsive avoidance, by doing extra research for a post--"maybe this time I will find exactly the right thing." It's like a high, and full of expectation, which quickly crashes to the ground when the searching drags on, my body gets tired, and my mood falls into depression, and yet OCD still claims that it's not worth taking the chance to actually do the writing and purposely let it be imperfect.

Right now I am learning that OCD is on the side of whatever painful things I believe about myself. I do not want to collude with that perniciousness. It comes down to avoidance. OCD would have me avoid so many things, because of a fear of making mistakes, that I would end up avoiding my whole life, and I did this for many years. When I do Exposures, I have the chance to actually live my life. This isn't to say there's no pain in my life, but that there is a possibility of joy as well.

Anxiety in Disguise

Fellow OCD Sufferer, from OCD Reflections, had a comment on my recent post about the History of Exposure Therapy that has me thinking. She talks about the possibility of habituation to anxiety when it seems "more like a biological reaction - when I can feel my heart beat faster, butterflies in my stomach. . .my OCD fears don't bring about that sort of visceral 'anxiety'." Instead it is rumination, in her head.

I've noticed this in my own OCD experience, that in a lot of my wanting to be "complete" or have something feel "right" doesn't register on my radar as "anxiety." Sometimes I feel like all the stuff going on in my head is sealed in a black box, and I can't get a good look. I know I do feel uncomfortable and uneasy if I contemplate moving on from a task if I don't feel finished(and yet, I rarely feel finished, so I'm waiting for something illusory), and this results in a dialog with myself about why I'm not moving on, when I don't feel severely anxious in a stereotypical way, and then my mood deteriorates as I get more self-critical.

A question that helps me identify what is going on in the black box:

What is my feared consequence if I don't do something the "right" way?
My therapist emphasizes that if someone had my fears of what would happen, they wouldn't want to do things either. I fear if I make a mistake, I will be a failure, worthless, and my defectiveness will haunt me forever. So yeah, that might make avoiding doing anything somewhat appealing!

He was telling me about some recent research showing some people are exquisitely sensitive to anxiety, and will search for ways to avoid feeling it. The vague tightness in my chest, the heat in my face, the heaviness in my muscles, the diffuse sense of being off kilter--not exactly a panic attack, not classically "anxious" with a capital A--but I quickly go into avoidance when I feel this way--avoid doing anything that makes me feel this way, like living my life, with the possibility of making mistakes, leaving things out, being incomplete.

Things like taking a shower even if I feel a resistance, a nagging fear that it's the wrong task at that moment, or leaving the house early enough to meet a friend, rather than getting on the computer and reading every single email message in my inbox before I leave. All the unfinished tasks call to me as I get ready to leave--the dining room table is "clear me, clear me!" and the sweater on the chair says "take me upstairs" and the email that I've ignored for a week suddenly clamor to be read. As Fellow Sufferer continues:

I know that exposure should also work for this type of "anxiety," but sometimes it's hard to conceptualize how changing my behavior will change my opinion about the way something "has to" be done.

I've been here! Many times. For me, it is sometimes a stalling tactic on the part of my OCD--"get it all worked out before you even start"--"know everything in advance, before you begin." When my OCD says, "Do it this way. Do it perfectly. Or don't do it at all" I divert into distraction so quickly I often don't notice I've done it, and go into avoidance mode, which ultimately comes back to haunt me when I snap out if it hours later, and I haven't done the things I really value in my life, like make art, or be with friends, or write this blog. My "regular" anxiety is probably a fraction of the intensity of all the anxiety I fear is waiting for me if I stop ruminating or compulsing or distracting myself.

My therapist says the ultimate goal is to do things in the wrong way, at the wrong time, that this is when I can make a break for freedom. The times I do something instead of avoiding, and see that I survive, even if it sucks at that moment, I am reaching into the black box and adding the possibility of light. The human desire to avoid feeling worthless or inadequate is powerful--and since so much of our selves are molded when we are young, and still thinking concretely it gets all tangled up in our nervous system--and by the time we can get some distance, we don't always realize that the concrete thinking isn't serving us well. Fleeing pain when you are 5, and have no income, no independence, no real options--that makes sense. Now I'm almost 45, and attempting to do things perfectly in hopes I will loved and valued creates even more pain.

Part 3 : The History of Exposure Therapy: Hans Eysenck and Learned Behavior

Hans Eysenck was yet another British psychologist who explored behavior therapy beginning in the 1950's, and who wrote a damning article in 1952 about the ineffectiveness of psychotherapy. As Freud envisioned it, a psychotherapist could take the process of psychotherapy and deduce the facts from it, rather than studying what the facts actually were. I am staggered by the traces of this that still affect the practice of therapy in the 21st century. I have vague memories of reading about behavior therapy in social studies class, and the fear that people would be reduced to laboratory rats conditioned to do tasks for food. But there is something immensely liberating in the idea that our symptoms are in part a "learned behavior" which is unadaptive, and which can be unlearned.

It's as if we are running our own little laboratory within our own mind every time we have an obsessive thought, feel intense anxiety, and then apply a compulsion that reduces the anxiety quickly, but then rebounds in the long term.

In 1960, his article, Personality and Behaviour Therapy(Proc R Soc Med. 1960 July; 53(7): 504–508), he explores the uses of BT in "neuroses," a term not as popular as it once was. He cites the study from 1920 about "little Albert," an 11 month old boy who was conditioned to fear rats because whenever he reached for the animal, the experimenter would make a loud noise. This of course is probably where my vague uneasiness comes from, since freaking out small children is not acceptable. These early studies may be the roots of the discomfort many current therapists have about Exposure and Response Therapy, but it is worth stepping back from the old history and consider the even older history of Freudian psychoanalysis which brought a whole tradition of showing patients ink blots, asking what they saw, and building elaborate theories of their personality based on a puddle of ink.

The point that really stuck with me was Eysenck's description of avoidance--if Albert could've been exposed to a white rat for a long period of time, without the loud noise, the fear could be undone, but as he ironically puts it, "Little Albert is a free agent," and is going to avoid even the chance of encountering a white rat, thereby never getting a chance to break free of the fear. If we are willing to risk feeling the initial fear liberty is possible. I know that it feels as if we face the fear every day, we do things we don't want to do, and yet the OCD persists.

This is a frustrating and painful place to be in. I make a phone call, and it actually goes ok, but by the next time I'm anxious again as if I'd never done it before. It's taken me a long time to comprehend that I've had much more practice avoiding phone calls than making them, and what we practice tends to get better. Slogging through the anxiousness of the initial surge of fear without my compulsions sucks, but persistence in practicing strengthens the possibility of getting better.

Part 2: The History of Exposure Therapy: Albert Bandura and Guided Mastery

As I contemplated what to write next in the series on the History of Exposure and Response Prevention Therapy(ERP), I decided to pick the first article in the pile of ones I had found, and came up with Swimming against the mainstream: the early years from chilly tributary to transformative mainstream, by Albert Bandura, Behavior and Research Therapy, 42(2004): 613-30.

I know Bandura's name from being a teaching assistant for a Health Behavior class(an ironic position for a woman with Health Anxiety), and the professor's discussion of Bandura's concept of Self Efficacy: the belief in our own capabilities to get things done. For myself, I had little belief that I could do anything to change my compulsive behaviors or deal with the obsessive thoughts, and this is truly disheartening.

ERP is a form of Behavior Therapy(BT), and Bandura traces his involvement in the history of BT, starting in the 1950's. The dominant form of treatment for psychological problems was Psychodynamic--the descendants of Freud, the heavy dependence on the therapist interpreting what the patient says in terms of things simmering in the unconscious, and searching for underlying meaning.

To directly deal with a behavior that causes suffering was considered superficial, inadequate, but Bandura noticed how people who modified their behavior(ie. stopping drinking) in one way, had changes throughout other aspects of their lives. He published an article in 1963 on psychotherapy as a learning process, and it generated huge interest--including from Victor Meyer, featured in my last post. The response from more traditional psychotherapists was resolutely negative--BT was dangerous! It would lead to "symptom substitutions" and all that unconscious stuff stewing would burst out.

In meeting others with OCD in support groups or at the IOCDF conference, and reading the OCD-Support List, and comments from readers of this blog, I am taken aback by how, in mainstream treatment of OCD by therapists of a general psychodynamic bent, they still want to find the underlying cause of the obsessions and compulsions, to the exclusion of actually addressing the behavior itself. This can lead to OCD hell--especially for those of us with existential OCD questioning of everything we do anyway. And Cognitive Therapy can also fall into the same hell, with analyzing our thought distortions ad infinitum.

This is not to say that the content of our minds was not important: there were those who were also interested in thoughts and beliefs, within the context of BT, and argued that people are self-examiners of their own functioning, that they as self-aware beings, we can influence our own environment, hence adding the "C" to "CBT"--Cognitive Behavioral Therapy.

He worked with people who had phobias, and I recognized the core truth in what he says, "When people avoid what they dread, they lose touch with the reality of what they shun." If a person with agoraphobia can test their dread by leaving the house and surviving, then they can get better, but Bandura understood the reality that

Intractable phobics, of course, are not about to do what they dread.

Yeah. I see myself in this. Bandura endeavored to create an environment where people could move toward that experience of getting back in touch with the reality that they shun. Bandura developed a treatment he called Guided Mastery, which strikes me as having elements of ERP:

• Modeling of the behavior by the therapist or other support person
• Following a graduated set of subtasks from easiest to most difficult
• Joint performance with the therapist of the feared task
• Performing the feared activity for only a short time, and gradually extending the time
• Increasingly challenging oneself in order to reclaim life
  

And then we come back to self-efficacy, which I learned about so many years ago.

Unless people believe they can produce desired effects by their actions they have little incentive to act or to persevere in the face of difficulties. Whatever other factors serve as motivators, they are rooted in the core belief that one has the power to effect changes by ones actions.

He argues that a good therapist arranges things for others in such a way that allows for success and "avoids placing them prematurely in situations where they are likely to fail," and emphasizes that if one can learn to see failure as informative rather than demoralizing, one can become resilient.

What can you do to encourage your own successes?

Part 1: History of Exposure Therapy for OCD: Dr. Victor Meyer and Ritual Prevention

The first obstacle to writing about the history of Exposure Therapy is, of course, my rituals of researching things indefinitely in hopes of being absolutely certain I haven't missed anything, and a long pattern of information hoarding. But here I am, after realizing I need to construct this series of posts as an Exposure--ie. pick a place to start without exhaustive information or a PhD thesis.*

The history of Exposure and Response Prevention Therapy(ERP) is scattered in journal articles and introductory paragraphs in books about anxiety disorders. A site that gathers information together for a fascinating read is The History of Obsessive Compulsive Disorder, written by an anonymous historian who suffers from OCD.

A name that appears often is Victor Meyer, British psychologist, who published a key article, Modification of expectations in cases with obsessional rituals. (Behaviour and Research Therapy 1966 Nov;4(4):273-80) This article isn't available in free full text, but I found a subsequent article that caught my interest [There's a lot of OCD noise in my head right now, 'just one more search,' 'you aren't done.' Yeah, I know.] Ritual prevention in obsessional patients, by Meyer and Levy, Proceedings of the Royal Society of Medicine. 1971 Nov;64(11):1115-8.

I am sobered by the bleak picture painted in much of the early and mid 20th century writings on the treatment of severe OCD, and the 1971 article refers to repeated leucotomy(ie. a kind of lobotomy) in some cases. Levy and Meyer report on a follow-up study of patients treated by interruption of their rituals. The fear had been that if someone interrupted a ritual, the person with OCD would have overwhelming anxiety or aggressive outbursts. These therapists ventured forward, and named the treatment "apotrepic therapy" from the Greek word meaning to turn away, deter or dissuade.

The sufferers were inpatients, incapacitated by their OCD, and with whom other methods of treatment had failed. I am trying to imagine this pivotal moment, a kind of stepping into the fray to break up a fight and fearing getting punched in the process. At least the researchers knew these people had OCD and that interfering with their rituals could be difficult. A couple years ago, I met someone who as a child had aggressive outbursts when his rituals were prevented by parents or teachers, and no one knew he had OCD and he was sent away to a school for kids with severe behavior problems.

Meyer's treatment consisted of instructing nurses to continually supervise patients during waking hours and preventing them from carrying out any rituals, either through engaging in distraction, discussion, or mild physical restraint(only resorted to with the patient's agreement.) The prevention of rituals was maintained for 1-4 weeks, during which the patients were gradually exposed to situations that evoked the rituals in the first place, and then supervision was also gradually diminished.

The results showed not only that compulsive behavior decreased, but that instead of the emergence of overwhelming anxiety, there was usually a decrease in anxiety and depression. The study was preliminary, but very intriguing. Some of the factors the authors attributed to the success were:

• Incorporating ritual prevention into family life, since family members often get drawn into helping complete rituals.
• Modeling by the supervisor who would perform whatever action the person with OCD was avoiding, ie. if they wouldn't touch a doorknob, the nurse would repeatedly touch the knob.
• "Alteration in Expectancies"--Meyer's assertion that failure to perform the ritual does not necessarily lead to the feared consequence.

The frustrating part for the authors was the stressful and time consuming nature of the treatment for all involved. For Meyer and Levy, they were trying something novel and very different from leucotomy or psychoanalysis, and they saw great potential, but also were aware of the difficulties, which eerily foreshadow some of the moments on VH1's The OCD Project. I end with a quote from the end of the article about interruption of rituals:

. . .we urge that this should only be done where the staff concerned can have the closest supervision and the fullest support. The line between firm but sympathetic control and unpleasant and inhumane bullying is a thin one indeed and all too easy to cross when one has devoted a lot of time and energy to a patient who relentlessly and monotonously pursues an unchanging course.

*This is way shorter than it would've been in the past, before I got treatment for my OCD, but man, it does still seem somewhat thesis-like. . .

Why do Exposure Therapy?

So here's the thing. Exposure Therapy for OCD is asking you to do what you don't want to do. If it were in flow chart form it would be boiled down to "Don't want to do it? Do it." This can be a hard sell. I pity the poor Exposure Therapists who get to present this to someone suffering with obsessions and compulsions.

In my last post I wrote about delaying getting on the computer, and doing this as an Exposure. Why would I do this? I feel anxious when I don't turn the computer on. I have too much time to ruminate about my anxieties if I am not distracting myself. But there is part of me that has dreams, and wants to live my life, not live the life OCD chooses for me. OCD is all about getting the anxiety level down by doing a compulsion; the rest of your life be damned.

I am not talking about being abusive, or harsh or punishing. I may take infinitely small steps in my Exposures, but it's not a race, or a TV show, and doing what I don't want to do is scary and takes courage and I have people in my life who understand that and encourage me. Exposure Therapy isn't a religion that I must follow, but a treatment that many clinicians have worked on developing over the past 40 years or so, based on observing what works. They aren't just making this stuff up.

Now, there are still gaps and shortcomings in our current treatments for OCD, but I will be writing some future posts on the history of OCD treatment, highlighting the breakthroughs and evolution of Exposure and Response Prevention Therapy. 40 years ago many thought patients with OCD were hopeless, and I want to pay tribute to those who searched for an answer, who believed hope was possible.

Related:
Part 1: The History of Exposure Therapy: Dr. Victor Meyer and Ritual Prevention

Delaying Compulsive Internet Searching: Hard and Yet Rewarding

Thursday I didn't get on the computer until 10:30 am. It was one of my goals from my OCD support group to pick a day this week to delay sitting down in front of the computer. It was definitely an Exposure. When I start websearching, I am in a kind of groggy trance. Searching the internet distracts me from anxiety and fear and is a compulsion. Spending 3 hours on my own time was a challenge.

In the past, I've regarded any improvement in my OCD or a "good day" as a fluke, and have a desperate sense of wanting it to last, and fearing that it won't. It's as if I see OCD as the weather, a climate that can change capriciously. But if I turn on the computer, I am stepping into the storm. It feels like I'm in a calm place at first, but it's actually the eye of the hurricane, and deceptive in its stillness. I go into a zone of deeply ingrained habit and muscle memory, into stiffness in my back, shoulders, neck and hands, and by the time I get off the computer, I am sapped of energy and my anxiety level rebounds back up, as I see how much time I lost. Then it starts all over, getting back on the computer to numb myself again.

So Thursday it was me alone in the house, wanting to flee this Exposure, wanting to turn on the computer, and at the same time marveling at how much I can get done when I don't turn the computer on. The OCD wants to seize hold of this and berate me for not doing the Exposure sooner, or more often. It's amazing how contradictory my OCD is--advocating for both complete compulsive immersion online, and for perfectly doing my Exposures. If the OCD wasn't intertwined with the whole apparatus of my anxiety, I'd call it out right away, but it has a secret weapon, my nervous system, my feelings of dread, nausea, and panic, but I'm learning to question the OCD's credibility.

The Lonely Pilgrim: The Isolation of Relationship OCD

Today I found a quote from the lyrics of Bruce Springtsteen's "Brilliant Disguise"
which encapsulated the sadness of the "Lonely Pilgrim's" voice:

God have mercy on the man
Who doubts what he is sure of.

I know this song, and have the album, but I haven't listened to it in awhile, and today it struck me as an achingly accurate description of OCD, particularly what some call Relationship OCD. The character in the song wants to make a real connection with the woman he loves, and yet cannot be certain of what is in her mind, or even in his own. He doesn't trust himself.

It is part of the human condition that we can't read minds, we can't really know what someone else is thinking, and this can be very lonely, but OCD grabs hold of it and intensifies the suffering with demands of knowing for sure what the other is thinking or feeling, or wanting to be sure of loving someone.

We are feeling creatures, but OCD has no mercy and erodes essential feelings of love and trust by putting the burden on the mind to figure it all out, get reassurance, guarantees, documentation and checking to make sure the feelings are still there. A quick way to lose connection with someone you love is to get lost in an OCD loop of verification within your own mind. I did this for many years in my marriage, wanting to know what physical connection "meant" and how it was supposed to feel, and compulsively going over any touch in my mind, trying to establish if it felt good, was I sure, how did I know, was I doing it right?

And when the circumstances and history of your life seem to confirm the OCD fears, that makes it even harder.

Well I've tried so hard baby
But I just can't see
What a woman like you
Is doing with me

I grew from girl into woman into the belief that no one would ever love me because I was essentially defective, and the OCD latched onto this with a vengeance, and ever increased the rumination and fear. A whole string of compulsive questions about what was wrong with me, and why couldn't I change it, and analyzing my every thought and sensation.

My husband and I actually were in a kind of "brilliant disguise," not really telling each other what we were thinking or feeling, but my OCD couldn't protect me from that, and in fact made us even farther apart. He could be in the room, right next to me, and I was far far away in my compulsing. We both found the courage to actually know each other, with the help of a therapist, and this helped immensely when I began Exposure Therapy for my OCD, since I could talk to him about how I was struggling, and at the same know that if he needed a break, he would tell me.

Are there any songs that are meaningful to you in dealing with your OCD?

How do I know when I'm done? OCD and the Desire for Complete Assurance

OCD affects aspects of human experience that most people don't think about, or only fleetingly. It's not that OCD is totally alien, but it is more severe than what people without OCD experience. I have OCD but don't usually check switches and such. But when leaving on vacation, a few years ago, I was halfway out of town and couldn't remember if I locked the door, and went back to check. Everyone has had a day where they aren't sure, and go back to check. Sometimes special circumstances like vacation will make you more aware of the consequences of an unlocked door.

Usually someone without the compulsion to check doesn't need to remember if they locked something or turned off a switch or a knob, because they do it, and move on without even thinking about it. It feels "done" but it's barely conscious, and they flow into the next actions of their day. OCD can disrupt every aspect of the flow of life. Someone with OCD can turn off the light switch, and stand there in the dark and still not be absolutely certain they turned it off, because they get a surge of anxiety that is gut wrenching, and a host of possible feared consequences, ie. "If I don't turn this off, a circuit could short and burn the house down. So I'd better keep checking."

The other day I watched my husband search for a muffin recipe online. He looked at a couple, one fit his ingredient list, and he hit print. He knew he was done. I could even say he "felt" done, but it's so a part of him that he doesn't really feel it as much as keep moving in the momentum of what he wants to get done. Part of my OCD is not feeling finished, not feeling I've fulfilled my goal, and I'm well into page 10 or more on Google when looking for a recipe. It's like I don't have an "off switch," and I am very likely to feel anxious if I don't feel "just right" or "done" and ironically, my OCD pretty much guarantees I won't get that feeling, no matter how much compulsive searching for the perfect thing.

Even when I find something that fits my criteria, I don't believe it, because I want to be certain that it's the right thing, and I'll feel anxious if I take the chance of printing something from page one. OCD isn't about logic. This can frustrate both the person with OCD and their friends and family. There is a tendency to assume if you explain the illogic, that this will solve the problem. "You are standing in the dark. Of course the light switch is off." "You've checked 5 review sites, and they all recommend the same product--why do you have to keep looking?"

I've always been fascinated by phenomenology--the attempt to understand what someone's experience is from the inside, the lived sensations of consciousness. OCD is that moment of wondering if you locked the door, and thinking you probably did, but having dire visions of thieves in your house while on vacation. You feel anxious. You don't want to ruin your vacation worrying about this. You drive back to check the door. But OCD will keep generating those moments of stabbing fear, even after you've checked. Did I really check? How can I be sure? There's no stopping point.

Cognitive Behavioral Therapy can get hung up at this point if the instruction is to guess the probability of something bad happening, and how much of it would be your responsibility--it could be .00001% and the OCD is still going to be clamoring about no risk being acceptable. For me Exposure Therapy has involved choosing something off the first page of Google, even if I break into a cold sweat, to help retrain my brain recognize that I'm done and can move on. I spent years waiting for fanfare and illuminated signs that a decision was right so I wouldn't have to feel anxious, but I am learning that most decisions don't get that kind of certainty, and that I can actually live well in spite of this.

Email and the OCD Fear of Saying the Wrong Thing

Email was like a miracle. I went to graduate school in 1993, and one of the perks was an email address. Since making phone calls filled me with dread, email was like getting released from jail, or pardoned. I loved its asynchronous nature whereby I could send a message and the other person would read it without my having to witness it, or respond to it in real time, and vice versa, when I received an email I could spend as much time as I needed to get my response right.

Of course, my OCD loved email, because I could delay actions that caused me great anxiety, like spontaneous speaking, but slowly I began to realize that email had its own set of anxieties. Email didn't erase my compulsion to making sure I didn't say the wrong thing, and most likely strengthened my fear of making a mistake. Writing email consumed a lot of time, because the using the "Send" command began to feel full of trepidation. Once I sent my email, I couldn't take it back. Pieces of messages would pop into my head, as I retraced all the nuances. I dreaded this reconstructive process, because it aggravated all my fears of saying something wrong, every time I listened to my own message in my head.

Responding to email was exhausting. The written word has a permanent quality, an inflexibility, especially in email where there isn't tone of voice(I certainly didn't know anything about "smileys") or facial expression, and I interpreted emails as if they were a holy text. What does this mean? What should I say in response? Will this correspondent think ill of me? But I chose email to communicate 90% of the time(7% consisted of real paper mail, which in a pre-computer era, involved lots of rewriting, and discarding whole pages if I made a mistake in expression, and the other 3% was on the phone under duress).

I chose email even when I started to realize that in some cases I would save a lot of agonizing by calling the person, but even though I could see that the email would turn into a convoluted dance of "Did I say the write thing? Have they gotten it yet? Why aren't they responding? I really need to know the answer to this question. Am I going to have to call, and then they will think I'm weird for emailing and then calling?" I started fearing opening my email, because of anticipating negative responses to my messages, and the longer I left a message unopened, the worse the anxiety became, until I assumed that it must be dangerous to open my emails, or why would I be so scared?

One of the exposures I did in OCD therapy was opening messages right away, especially ones that I was afraid of. I gritted my teeth the whole time, but I'd seen how my anxiety escalated the longer I waited. I also practiced writing "inadequate" responses--short, quick, unrehearsed. Which, actually is what email is--somewhere between formal letters and phone calls. I'm never going to be a person who enjoys talking on the phone(unlike my friend J. who enjoys phone calls so much that even if calling was less efficient than looking up info on a website, would still call, just to talk to people), and like Miss Manners I do agree that the phone ringing is not a "command" to pick it up--I can decide when to take calls--but I need to keep an eye on the OCD which will find a million ways to avoid saying the "wrong thing" as if we can definitively ensure that, as much as we might want to.

Related Posts:
Telephone Phobia: Fear of Making Phone Calls
Ritualizing in my Head: Retracing
Verbatims

Unhelpful Strategies: Thought Stopping for OCD

This strategy has been around a long time, and never seems to go away. The premise is that you snap a rubber band on your wrist, or imagine a giant stop sign, or shout "stop", whenever you have an intrusive thought.

I have an early memory of being 8 or 9 and trying to stop thinking. I held my breath. I stood still. But I couldn't stop. I was baffled by this phenomenon. No matter how much I tried to make my mind blank, I could hear my thoughts of "Stop thinking. Have I stopped yet? Why am I still thinking?"

Thought Stopping sounds logical on the face of it. You have an intrusive thought. It makes you anxious. You want it to go away. You stop it. Except that I couldn't stop. It wasn't that I didn't try hard enough. It was that I tried too hard. Every time I jumped in to push the thoughts out, through figuring them out, rationalizing, analyzing, confessing them, researching them, websearching and other forms of distraction, cueing my relaxation exercises, my deep breathing or reassuring myself that it would be ok, the thoughts rebounded and came back even stronger.

If Thought Stopping worked, would anyone have OCD intrusive thoughts? We could just make them vanish with the snap on the wrist. Our minds are immensely creative and generative. All sorts of thoughts pop in, and if we just let them alone, they tend to pass. But if you have OCD it's a struggle to let them pass, and the initial wrestling with them does give a hit of anxiety relief, but then it's like signaling your brain that this thought is truly dangerous, so if it comes back, try to kill it, and the cycle continues.

I reclaimed a lot of my life back by doing Exposure and Response Prevention Therapy. I recorded scripts of the thoughts, and listened to them repeatedly until my anxiety level came down on its own. I had a therapist helping me to do this.

For More Information:

Am I Still Anxious? Does this Still Bother Me?
Talking to OCD: The Hazards of Talk Therapy
Freedom from Obsessive Compulsive Disorder by Jonathan Grayson


Hayes and his Action and Commitment Therapy colleagues have been researching the phenomenon of trying to make thoughts go away, and how it doesn't work.
For a useful summary of ACT, Dr. Russell Smith has a good article:Simple Overview of ACT: To download a simple, non-technical, easy-to-read overview of ACT ( called 'Embracing Your Demons', an article he wrote for Psychotherapy Australia magazine) click here.

Going Back to My OCD Support Group

I happened to cross paths with someone from the OCD Support Group I used to attend, and she invited me to come back as I told her about having difficulty with a lot of unstructured time since being jobless. I went this week, and realized I hadn't been there in almost 2 years.

I like the immense practicality of this group. After a discussion, we get into smaller groups, each with a seasoned member to lead, and each person picks a goal for the next 2 weeks until the next meeting. The group can help generate ideas for exposures, which can be hard to do by yourself if you are feeling anxious and sucked into the compulsing.

The key is to choose a goal that you are willing to do, and it's like a secret weapon against OCD. The most innocuous sounding goals often lead to important change, like a catalyst setting off your own self-confidence and self-efficacy.

The defining questions for the goal are:

• What action will you do?
• When will you do it?
• How often will you do it?

OCD thrives on vagueness in goals, like "I'll try to obsess less." My perfectionistic OCD gets set off by the idea of small steps--the squawking voice demands "all or nothing at all" but that leads to being stuck in the OCD, because if I don't do a small step, I usually do nothing at all. My goal is to write some of the tasks I actually want to get done(as opposed to what my OCD wants, ie. reduction in anxiety at all costs)on index cards and once per day randomly pick a card and do the task. I've practiced avoidance for so long that it's quite an exposure to get something done, without ruminating on whether it's the right thing at the right time. The other goal I chose was to pick one day a week where I will delay getting on the computer until after noon, to give myself a chance to get other things done.

What small step can you choose to take this week?

Related:
Challenging OCD One Step At a Time
List of OCD Support Groups for Adults in the US

OCD Squawking

There's not a lot of room between noticing something, and being alarmed by it when you have OCD. I was checking my email this morning, and noticed an achy feeling in the vicinity of my bladder, and suddenly it's red alert, squawk, squawk, squawk.

An early strategy at a young age was I would stop everything and focus on the sensation, which soon would lead to not feeling anything else but that sensation, and then despair that that's all I could feel. I have a diary from when I was 11, with Holly Hobbie on the front cover, a tiny lock and key and gold dusted page edges, and several entries are descriptions of things I've noticed in my body, and trying to reassure myself, "Not to worry."

By the time I was an adult, I was convinced that if I had any pressure or awareness of my bladder, then I couldn't focus on anything else, couldn't enjoy whatever I was doing at the time. As soon as my internal conversation plunged into "I can't enjoy this vacation, this movie, this walk, this concert. . .because this sensation in my body is intruding, and it's all I can think about," I would plummet into hopelessness.

Part of this is simply being human and having consciousness--we are aware we are going to die, we remember sad things from the past, we can ask "what if?" But OCD wants to control what we are conscious of, either by making certain thoughts go away, or insisting the future be know-able. Squawk. Squawk. What sucks is that some painful sensations and memories never go away, and OCD gets locked into combat with them, making them even worse, but lying and saying, "No, really, I can make this go away. Just stick with me. Don't give in. Don't do anything until I solve this with compulsions."

I do have a lot more freedom since I started doing exposures in therapy, and outside of therapy. For a couple years I would drive by a fabulous Mom and Pop donut shop on my way from therapy to work, right around the time I started to feel pressure in my bladder from the long drive, but I wanted those donuts, and I'd stop to get a couple. At first I'd tell myself to wait until I got to work, so I could hit the bathroom, and then enjoy the donuts perfectly, but they were so good, I'd end up eating them on the drive.

What I discovered is that although I preferred not having the bladder sensations, I could still enjoy other things(like donuts!) at the same time. This may not seem like rocket science, but when you have OCD, this was like knowing how to turn straw into gold, or water into wine.

What we practice we tend to get better at. My therapist likes to say this, and I sometimes find it irritating, but it took a year of practice to distance myself from bladder panic, which can sound daunting, but after 30+ years of being limited by my need to find a bathroom at all times, I am very grateful for my new freedom.

Related:
Do I have to go? Bladder Fears and OCD

Doing OCD Homework and Fear of Failing

Wednesday in therapy, Leonard had me record a description of the moment at which I feel the compulsion to ritualize, followed by my values list. My homework is to listen to it 12 times a day. The idea is that I will start building new connections to my values, so that when my anxiety spikes, my values have more of a chance of coming to the surface. I've had 15 years of a job where if I started to feel anxious, I could distract myself on the computer, and the habit is deeply ingrained. Now I have all this time at home since I lost my job, and the old critical perfectionist voice is getting loud. "You have all this time now. Why are you wasting it being compulsive?" Which then gets the OCD ramped up, because I don't want to have the thought that I am wasting time, or doing things imperfectly, and I get back on the computer to distract myself and waste more time.

Leonard's idea makes sense to me, but it almost seems to make too much sense(if that makes any sense!!) Some convoluted OCD logic, "This could work, but what if you try it and it doesn't work? And this proves you are a worthless failure. You'd better avoid doing it." I see the irony in the fact that there were many times I wanted to quit my job, because the OCD was so tied to walking into my office, feeling immediately incompetent and scared, and seeing the computer, sitting down and then wondering where the day went. Part of me hoped that if I didn't have the job, my OCD would go away. I remember starting on an SSRI, and having a bad dream that I was starting to feel better, but this meant I would have to stay at my job forever.

I suspected that quitting my job wouldn't eradicate my OCD, and that what I really needed was treatment for the OCD, before reevaluating what to do with my life. OCD isn't very sophisticated, and spent its time screaming, "You are wasting your life at this job," which sent me into a frenzy of compulsive distraction, but OCD couldn't give me any other alternative. And of course, it was the OCD that was mostly responsible for whatever wasting of my life I was doing at work. If there had been a video camera in my office, the film would've shown a woman sitting very still, moving the mouse barely perceptibly with her left hand(because she injured her right hand, and in order to keep websearching, had to switch to her left).

Today has been a lurching through various forms of perfectionism, but I listened to my recording 3 times today so far. I will give myself credit for that.

What do you want your life to be about? Acceptance & Commitment Therapy for OCD

My friend J. came over today for coffee, and I told her I was avoiding doing my therapy homework for tomorrow, writing down my values. Her eyes lit up and she said, "Oh, let's do it now, together." I think she would've made an excellent Exposure Therapist in another life! At first I was like "Crap." But enough of the healthy part of me said, ok, let's do it. J. lost her job just before I lost mine, and we are going some similar re-evaluations of our lives.

My therapist is having me work through "Get Out of Your Mind & Into Your Life: The New Acceptance and Commitment Therapy" by Steven C. Hayes, PhD. Some of the ideas of ACT are really useful for dealing with OCD, especially learning to observe your mind and let the noise be there, but doing what you really value in spite of it. At times the scientific language bogs me down, especially with an OCD desire to understand it perfectly, and I'm glad I'm working on it in the context of therapy, so I can get help with the perfectionistic tendencies.

My homework for tomorrow was to write down what I truly value in 10 different domains of my life, such as friendship, relationships, family, parenting, work, recreation, spirituality, citizenship, personal growth and learning, physical health and well being. J. set the timer for 1 minute for each category and we started writing what we want our lives to be about in each of these areas. Then Hayes asks us to re-read what we wrote, as if no one else would ever see it, and whether these are things we really value or whether they are things we think we are supposed to value. All of this is ripe for OCD over-interpretation, but framing the exercise as an exposure helped--writing things down in a minute, without knowing for sure if they really *truly* are my values, not to mention judging whether these are things I *should* value.

OCD only values reduction in anxiety--there isn't much else it cares for except certainty. When I do what my OCD demands, I get a temporary drop in anxiety, but I don't get to live much of my life. I value connections with people, and making art. I don't want my life to be about my rituals. The temptation is to fall back into my perfectionism OCD, and berate myself for ritualizing, as if somehow this will help me change. But one of my values is compassion, and persecuting myself for having OCD is not compassionate, and I am slowly learning how to have compassion for myself.

Sometimes the motivation to do exposures is hard to find because the anxiety is so gripping. My therapist is arguing that my values can help guide me, and help give me courage to face the OCD. What do you value? What motivates you to do exposures?

You can download the full 2-page version of the values chart here.

For a useful summary of ACT, Dr. Russell Harris has a good article:Simple Overview of ACT: To download a simple, non-technical, easy-to-read overview of ACT ( called 'Embracing Your Demons', an article he wrote for Psychotherapy Australia magazine) click here. I read this article several years before getting any treatment for my OCD, and it stayed with me.

Scrupulosity and the Body: Lunch with the Religious

Yesterday I walked into the middle of an exposure so surreal I thought maybe my therapist orchestrated it. I was meeting a friend for lunch at a restaurant that is part of a conference center. The parking lot was packed, and as I was circling around looking for a space, I started to notice the large number of bumper stickers about respecting life, marriage and chastity(the one I am still pondering is "Chastity is for lovers.") I walked into the lobby, and my friend was sitting there in a sea of nuns in full habit and priests in clerical collars, with some lay people mixed in.

There was a long line of various religious folk at the hostess desk, but fortunately I had a reservation. We were seated next to a man in a floor length black robe and a gold cross about 8 inches long, and people kept coming up to him to reverently say hello.

I went through several years of struggling with scrupulosity centered around Catholic theology, for instance, contraception being a sin. Of course the irony is that I am not Catholic. My first boyfriend was Catholic, and later I worked at a Catholic college, and being introduced some of the central Catholic issues set off a cascade of anxiety. This is the bizarre thing about having OCD--I can latch onto a thought, and wrestle with it hoping to make it go away because it disturbs me, but which has no connection to my actual beliefs. The thoughts that I feared were "What if contraception is wrong? What if I am going to hell? What if I am supposed to be Catholic?" And this is what makes dealing with scrupulosity incredibly hard--there will be people who do believe I should convert to Catholicism, who wouldn't interpret my anxiety as OCD, and this compounds the anxiety.

So there I was yesterday, enveloped in a conference about Catholic theology of the body, and I did ok. I was uncomfortable, but I focused on my friend, who is going through a hard time right now. I didn't go home and look up the conference, or research the agenda, or the supposed immorality of contraception, or sites that say a marriage without children is a sin, or read conservative Catholic websites like I used to do. At the worst of my scrupulousness, I was subscribing to a mailing list about natural family planning, trying to figure out if there was any way I was redeemable.

Yesterday I was even able to laugh at the over-the-top exposure material. Today I am feeling tired and unsteady, but I know for me the act of faith is choosing what I believe. Yes, that is exactly what will rile some people up--and I am learning to live with that.

Resources:
Although I am not Catholic, ironically I did find Scrupulous Anonymous to have some helpful articles:
Scrupulous Anonymous: Newsletter by Liguori Publications

The Scrupe Blog is moderated by a Lutheran Minister and often has quotes from religious folk who suffered from tormenting thoughts:
The Scrupe Blog

The first book I read on scrupulosity was psychologist's William Van Ornum's A Thousand Frightening Fantasies: Understanding and Healing Scrupulosity. The author did a survey of sufferers, and I realized I wasn't alone.

I heard Ian Osborn speak at one of the IOCDF Conference's and his talk about scrupulosity was very interesting.

Just One More Search: OCD and Information Overload

There's a discussion that threads through the OCD-Support group on Yahoo about providing information and changing beliefs as a way to treat OCD rather than doing exposures. When someone asks about a particular feared consequence in the OCD-Support group, there is almost always several people writing to reassure the person that what they fear won't happen, and sometimes a defensiveness about the basic human need for accurate information and compassion. What unfolds in many cases is that the person already knows the information(ie. how HIV is contracted), has had repeated tests, and asked the same questions many times.

A compulsion is usually the tip of the iceberg, with a lot of suffering underneath, and there are always people who will say, "That's not a compulsion, that's a good idea." At age 27, I once told a doctor I was anxious about skin cancer, and she said "Good, you should be." She didn't know that I was checking my moles constantly, researching skin cancer, and that none of this actually made me any better and identifying moles that might be abnormal. It's not compassion to encourage life eroding rituals.

In my experience, I could never get enough information. I've earned my living doing research, and I'm good at it. I read 12 books on OCD the first month I started treatment with Leonard, but it wasn't helping me since I was trying assuage the part of me that was afraid I didn't have the perfect treatment, and that I wouldn't get better.

Fortunately, I was able to be honest with my therapist about all the reading I was doing. He didn't fit the authoritarian stereotype of an Exposure Therapist, and he did give me some information, but it was information about the nature of the disorder, about the constant desire to have 100% certainty, and that his clients get better, but he couldn't give me an absolute guarantee, and asked me to consider taking the risk and doing the treatment, and not reading more books. He wasn't asking me to follow him unquestioned, or demanding I do what he wanted. He was appealing to the healthy observant part of myself that wanted to get better. We all have this part, no matter how buried under OCD.

A Perfect Schedule Does Not Exist

Yesterday in session with Leonard, I admitted my anxiety was up about doing a schedule, and I hadn't done one that week, so he suggested we do one right there in his office. Meh. I was up against the usual suspects--fear of choosing the wrong activity, at the wrong time, in the wrong quantity, and that failure to do everything would mean I was a defective human being. That's a lot to carry into schedule making!

Leonard argued that the *perfect right way to be* is only theoretical--it's not reality. There are things I really want to get done, and they are different things than what the OCD wants. I spent last week floundering around on the computer, getting stuck in one task and feeling like I must finish it, and then suddenly the day was over. So I got my notebook out in my therapist's office, and felt a surge of anticipatory anxiety, tightness in my chest and heat in my face. Actually picking things to do was not as bad as anticipating it(and the perfectionistic voice was squawking, "Why didn't you do the schedule sooner, since obviously if you'd just started it, you would be ok?" which is direct opposition to the previous squawking about "If you start a schedule, and do it wrong, you are doomed."

My OCD mind has a very limited understanding of time, or of how things get done, or how to be pragmatic. I imagine a perfect reality that I could obtain if I just tried harder, but in fact my life is happening right here, right now. Leonard suggested this is the true perfection--staying in the moment long enough to actually do what I value doing, and that aiming for perfection is a "young" strategy, a child's way of fixing pain, "Make it go away forever by doing everything just right." I remember being almost heart broken in my 20's when I would get a task done, and then there was another one to do, and it was such a disappointment to find I wasn't completely done.

To make things even more complicated, Leonard said I might discover my schedule needs to change based on what is happening at the time! He advocated for compassion with myself--that whatever I get done is more than I would've when completely entangled with OCD, and that the OC perfection voice will be loud, and I can just let it be, and go on with my day. The existential voice of doom wants to fix all of this, research the best tasks to do, or best organizers or read more books on OCD, but this is a danger signal--repairs, fix-its, or "figuring out" often lead to more OCD. Sometimes it feels like working without a net--up on the high wire, choosing things with wild abandon, but I do know my usual way of approaching my day leads to being trapped underground with no light to see my life.