OCD A to Z: T is For Therapy

The International OCD Foundation has a useful checklist of questions to ask of potential therapists for OCD, as well as a database of OCD therapists. There is evidence that Exposure and Response Prevention Therapy works for Obsessive Compulsive Disorder, and yet very few therapists who are actually trained to do it or who have even heard of it.

It's a bizarre thing that OCD symptoms in all their permutations sound incredibly familiar to me, but to therapists who are unfamiliar with OCD, they don't see the patterns. They are baffled, frustrated, or assume there are deeper issues that must be dealt with first and the symptoms will then go away. I have had several excellent therapists who cared deeply about me, and wanted only the best for me, and did indeed help me dramatically with other areas of my life, but who didn't know how to treat OCD or didn't even recognize that I had OCD.

There are some areas of the US with no trained ERP therapists, and this sucks, but I encourage you to persist in searching out help, whether by support groups, or therapists who work with Skype, or the telephone. The IOCDF also has a Guide to Low Cost Treatment Options for OCD.

Tips for Interviewing Therapists: What Should I Ask?

The following checklist from the IOCDF can help guide your search for the right therapist. The answers to most of these questions are available on the individual listings in the IOCDF Treatment Provider search engine, but it never hurts to ask a therapist yourself:

"What techniques do you use to treat OCD?"

If the therapist is vague, or does not mention cognitive behavior therapy (CBT) or Exposure and Response Prevention (ERP), use caution.

"Do you use Exposure and Response Prevention to treat OCD?"

Be cautious of therapists who say they use CBT, but won't be more specific.

"What is your training and background in treating OCD?"

If they say they went to a CBT psychology graduate program or did a post-doctoral fellowship in CBT, it is a good sign. Another positive is if a therapist says they are a member of the International OCD Foundation (IOCDF) or the Association of Behavioral and Cognitive Therapists (ABCT). Also, look for therapists who say they have attended specialized workshops or trainings offered by the IOCDF, like our Behavior Therapy Training Institute (BTTI) or Annual Conference.

"How much of your practice currently involves anxiety disorders?"

A good answer would be over 25%

"What is your attitude towards medicine in the treatment of OCD?"

If they are negative about medicine, this is a bad sign. Medicine can be an effective treatment for OCD.

"Are you willing to leave your office if needed to do behavior therapy?"

It is sometimes necessary to go out of the office to do effective ERP.

This has been adapted from: "How to Choose a Behavior Therapist" by Michael Jenike, M.D.

The Mindfulness Workbook for OCD: Just Right OCD

I was glad to see a chapter on this form of obsession of doing things "just right, " also known as symmetry OCD, organizational OCD, and perfectionism OCD.  The authors get the fact that the opposite of "just right" feeling is "feeling dead wrong," which has emotional intensity.

The one compulsion that resonated the most with me was:

• Checking to see see if things appear as you feel they should(for example, reviewing the placement of two pillows on a bed to make sure they are in the perfect position.)

When my health anxiety would be active, I would check whatever symptom I had against the opposite side of the body.  This summer I had a feeling of a something stuck in my throat, and my urge was to keep checking to see if my tonsils were parallel, and then feeling ashamed that I looked in the mirror, and berating myself for my vigilance.  

An Acceptance tool for Just Right OCD is allowing the "off" feeling to be there, noticing the body sensations, and carrying it with you "on your way to doing something greater than your compulsive fixing."  

An Assessment tool for Just Right OCD is dealing with all or nothing thinking.  When I used to sew for Home Ec class, I would become so fixated on any small asymmetry of top stitching, and therefore the whole garment was "ruined," even though other people would have a different frame of reference, and not even notice the stitches, but rather overall shape of the garment.  Ironically, I won an award for excellence in Home Economics in 9th grade, even as I was convinced any flaw meant I was incompetent.

Taking Action for Just Right OCD includes recognizing that focusing on perfection can mean a tiny trigger can feel as disturbing as something more obviously huge, so setting up a hierarchy of exposures can seem impossible.  

It's important to get in there and take any opportunity to let things feel "off" rather than trying to fix it.   Trying to decide if I had a hierarchy of exposures "just right" could take up all my time and it helped that my ERP therapist understood this and encouraged me to practice tolerating the thought that I might do my exposures wrong.  

Summary of Part 1 of The Mindfulness Workbook for OCD by Jon Hershfield and Tom Corboy.

New Harbinger Publications offered to send a review copy of The Mindfulness Workbook for OCD by Jon Hershfield and Tom Corboy(2013).  Since I was in the middle of taking a mindfulness class, it was interesting to read this book with specific connections to OCD.

I am familiar with the writing of Jon Hershfield, as he was the moderator of the online support group PureO for many years, and he had a way of describing obsessive thoughts and ways to face them that was very helpful.

Part 1 covers definition of mindfulness and cognitive behavioral therapy(CBT) terms.

The authors define mindfulness as, "the state of acknowledging and accepting whatever is happening in the present moment exactly as it is(p. 8)."  In my experience, when I have an anxious thought or sensation, I race way ahead of the present moment in trying to figure out what it is or what it means.

The authors argue that, "The problem of OCD isn't that you think too much.  It's that you confuse the intensity, volume or visibility of your thoughts with their importance(p. 12)."  Practicing hanging in there with the intensity or stickiness of the thoughts can allow your mindful self to choose what you want to do with your life, rather than listening to the loudest voice.

The book provides a cognitive behavioral therapy background on distortions of thinking that you can identify in your own thoughts, not as a way to "solve" or "figure out" the thoughts, but to practice seeing them as thoughts.  One of the things that really helped me when I was in therapy for OCD was writing down my thoughts as they happened, as if it were a transcript, but then labeling the distortions in the margin, so I got better at identifying what my mind was up to.

One such distortion is Catastrophizing/Predicting/Jumping to Conclusions.  Accepting I can't predict the future is a bedrock of mindfulness.   As scary as the uncertainty can be, the racing ahead brings forth even more fear.

The book does an overview of Exposure and Response Prevention therapy, and the use of Imaginal Exposure Scripts, another component that helped me in therapy.

Part 2 of the book addresses mindfulness and CBT for specific obsessions with a 3 step process.

1. Acceptance of the presence of OCD thoughts and feelings.  You are accepting that the thoughts are there, not any meaning that you attribute to those thoughts.
2. Assessment using CBT to assess the value of the OCD thoughts, as a nonpartial observer, labeling possible distortions, and returning to the present.
3. Action using behavioral skills to expose yourself to OCD thoughts in order to habituate to them and overcome your fears.

I suspect many readers will turn immediately to Part 2 in hopes of clues to particular obsessions, as the authors say, "The reason we separate obsessions into categories is that for every obsessive-compulsive cycle, there's a way to break it.  There's a way in, and knowing the way in is important  When you understand the mechanics of an obsession can identify the compulsions that hold it in place, you can begin the process of letting both of them go(p. 84)."

I will discuss some of these chapters in future posts, as well as some thoughts on the book as a whole.  

OCD Recovery as a Continuum Rather than All or Nothing

Right now I'm reading Monica Ramirez Basco's book Never Good Enough, about dealing with perfectionism. She is a cognitive behavioral therapist(CBT), and describes common thought patterns for people who are perfectionists, including "two basket thinking," where everything either falls into good or bad, right or wrong, safe or dangerous, done or undone, all or nothing, one basket or the other. Basco offers a continuum as the alternative, rating experiences, feelings or events on a scale of 0 to 100%.

Two basket thinking causes me a lot of distress, especially in relation to my OCD treatment, where I assumed I would go from having OCD to not having OCD, jumping from one basket to the other in a single leap, and anything inbetween was failure, hopelessness and despair.

Basco argues that most victories in life are small ones and if we discount those, we are missing much of our progress in pursuit of making the big jump. Paradoxically the harder I try to skip all the middle stuff and just make OCD go away, the more likely I will get stuck in an OCD flare-up, trying to accomplish something that is impossible. When I encourage myself, I gain more energy to fight my OCD and make that journey inbetween the two baskets.

Skin Cancer Anxiety: Fear Vigilance and All or Nothing Thinking

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

Challenging OCD One Step at a Time

Skype for OCD Study: Project SOS from Drexel University(Residents from PA, NJ, NY, ID, MD, CO, HI, IA, SD, WA, WV and WI may be eligible)

I was contacted by Project SOS of Drexel University, asking if I would advertise their study comparing two different types of Cognitive Behavioral Therapy/Exposure Therapy, administered via Skype. I am glad to pass on this information, and am glad that Drexel is funding research that examines factors related to the dissemination of effective, evidence based treatments for anxiety disorders.

Residents of the following states may be eligible:

Pennsylvania, New Jersey, Maryland, Colorado, Hawaii, Iowa, South Dakota, Washington, West Virginia, Wisconsin. JUST Added: New York, Idaho

Online Treatment Program for Obsessive Compulsive Disorder

Skype for OCD Study (Project S.O.S.)

General Study Information

Drexel University Anxiety Treatment and Research Program is providing treatment free of charge to eligible participants through the University's Department of Psychology. The research study seeks to examine the effectiveness of two variations of a specific type of Cognitive Behavior Therapy (i.e., Exposure and Ritual Prevention) for people with OCD. Treatment is delivered over a period of 16-18 sessions conducted via the videoconferencing program Skype.

Determine Eligibility to Enroll in Program

Let us know that you’re interested! To determine if you are eligible, please call (215) 553-7000 or email us at drexel.sos@gmail.com and provide us with your name and telephone number. Alternately, you can complete this contact form. However you choose to contact us, a member of our clinical team will be in touch with you promptly.

Here is our Project SOS Contact Information:

Phone: (215) 553-7000

Fax: (215) 762-4834

Mailing Address:
Anxiety Treatment and Research Program
Drexel University
Mail Stop 988
245 N. 15th Street
Philadelphia, PA 19102-1192

Email Address: drexel.sos@gmail.com

You can learn more about the eligibility process here.

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?

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.

Challenging OCD One Step at a Time

The expression "Not seeing the forest for the trees" resonates with my experience of being in the OCD. I get lost in these trees, seeing every rock, every bit of moss, tiny insects, and getting cold and exhausted. I've been practicing the skill of taking an aerial view and seeing the forest of this disorder as a whole. Often I am disappointed when I catch a glimpse from the treetops, and my heart sinks, "Oh, no, I'm obessing again," but seeing that I'm obsessing can be the first step to challenging the OCD.

What do you do when you realize you are obsessing and doing compulsions? Often I condemn myself, feel angry at myself, feel despair, and most detrimental, assume I've already ruined the day, and that there is no hope of salvaging it. OCD thrives in black-and-white thinking. Either the day is perfect or it is ruined. Either I am challenging my OCD all the time, or I am a failure. And OCD fully exploits this by dismissing how humans really learn, which is by trial and error, bit by bit, and my anxiety rockets up, and I do even more compulsions trying to get the anxiety back down.

When it comes to challenging OCD, anything above zero is good. I'm serious about this. At times it's hard, because my progress seems so meager, and that's why going to a support group helps. Members of my group knew that if I lasted 5 minutes before researching a health symptom, this was a victory, because in the past I'd be searching before I even realized it and the day would be gone.

At times OCD seems like something from Grimm's Fairytales. OCD tells a tale of a happy ending if you just do whatever it demands. Of course the original stories by the Grimm brothers are full of violence, fear and destruction, not nearly what we imagine to be a "fairytale" in our era. One way I challenge my OCD is to ask,

Is it promising something I can't really have? Is it offering an illusion of a happy ending?

If I am honest with myself, the answer is yes. OCD is promising I can know things in advance, omnisciently, and perfectly, that I can know absolutely that I am making the right decision, that I can protect everyone I love completely, that I can make sure bad things never ever happen. The more I listen to the OCD, the longer I wander in the thicket.

Related Post:
Going Back to my OCD Support Group

VH1's OCD Project Premiere: Reactions From Someone with OCD Part 1

I've been hearing a lot about the OCD Project on VH1. I don't have cable, but found the premiere online. The host is Dr. David Tolin, a clinical psychologist, founder of an Anxiety Center and who teaches at Yale. He's got credentials. He knows what OCD is and he knows how to do Exposure and Response Prevention(ERP) Therapy, but throw in the world of reality television and things get dramatized. The trailer for the show has Tolin licking the bottom of a shoe.

ERP is hard enough without it being portrayed for maximum revulsion. Exposure Therapy is about learning to live with uncertainty about how clean, safe, or right things are, and no human enjoys thinking about this kind of uncertainty. I am disturbed by the paradox that a tv show is actually showing a proven treatment for OCD, but in such a way that some people will be scared away from trying it. Not everyone will be scared--some people are so tormented by their OCD and combined with a certain personality, kick OCD to the curb with big gestures, but most of us take small steps at a time.

How often do you need to lick a shoe in real life? Treating OCD is more about the subtle issues in daily living. Dr. Jonathan Grayson has a vignette on his blog, entitled "'Normal' People Don't Know What They are Doing, "about pouring potato chips on the floor at a lecture on OCD and proceeding to eat some, and offers to share. There's a general "ewww" response from the college kids, but then he asks them if they sit on the floor at parties, and many say yes. Then he asks if they wash their hands before eating snacks at a party, and many do not. As he says,

”Normals” may say they won’t eat after touching the floor, but they don’t really know what they are doing.

I don't have contamination OCD, and this vignette made me think of how I put my shoes on, and then later might lick my finger to get a plastic bag open, or pick something up from the floor and then later pop a piece of candy into my mouth, all without washing my hands first. I'm inconsistent. If I pet the cat, I wash hands before food prep. This is salient in my mind, but if I pet the cat and then walk by free cookies, I'll pick one up and eat it without thinking about it. I'm not talking about a wanton recklessness here. If we were to be 100% consistent about avoiding contamination, we would be paralyzed by the "dirty world" we live in.

I joked with my therapist that our sessions wouldn't work on tv, and he said, "On PBS!" which made me laugh.

Core Beliefs Matter in Treatment of OCD

Cognitive Behavioral Therapists often refer to "Core Beliefs" about self and the world. These beliefs shape everything we do, including Exposure Therapy for OCD. These beliefs matter.

• I must be perfect or I'm a failure and therefore worthless.
• I must do everything right on the very first try.
• I must never make a mistake.

These beliefs are on auto-pilot. They guide my actions before I even realize it. OCD feeds on these beliefs, and uses every opportunity to remind me that I shouldn't do the things I fear, or do my treatment, because the stakes are too high. Another bit of CBT jargon is "Feared Consequences," and mine are dire.

• If I make a mistake, this will prove I am worthless, and I will have no hope of peace or joy in my life.
  
• I will implode from the pressure of my defectiveness.
  
• I will go crazy from the anxiety.

Leonard had quite a lot to slog through with me to get to the point of doing Exposure and Response Prevention. ERP sounds daunting enough--"Do what you don't want to do in order to get better,"--without adding "And do it perfectly the first time." ERP works by taking it step by step, starting with something tolerable and moving up a ladder or hierarchy of feared actions. Contending with the a harsh critical voice yelling, "Whatever you do isn't enough" paralyzed me at first.

What are your core beliefs? Are they true for everyone, or only for yourself?

Skin Cancer Anxiety: Fear, Vigilance and All or Nothing Thinking

About 10 years ago, I noticed a small bump at the top of my ear, under the helix, and I'd fool with it, and it would bleed and then scab over. With my selective OCD hypervision, since the bump was hidden from my sight, I went at least 6 months before I started to worry about it. I did acrobatics with a mirror, but couldn't get a good view. I'd had several moles removed over the years, none of which were malignant, and I felt ashamed of my vigilance, and sad about the little white scars. But it was bleeding and never completely healed, and this was unusual. This was one of those things on a public health warning poster.

After a deluge of anxiety and indecision, I made an appointment. I'd seen this doctor several times before for anxiety symptoms--a gland I thought was swollen, a bladder infection that turned out not to be one, and had asked for a referral to a psychologist. I will credit him with telling me I'd done the right thing in coming to have him check it out, but then he said, "I don't know what it is, but it's benign. Maybe it's an infection." He put a dab of antibiotic ointment on it, told me not to traumatize it, and said if it changes, come back in.

This only stoked my anxiety, and my OCD need for certainty. To be told "I don't know what it is, but it's fine" was enough to cause a firestorm of fear. I felt too ashamed of my anxiety history to assert myself and say, "It's bleeding. I'm not gouging it, it just bleeds at the slightest provocation. I've had it for over a year." I may have mentioned some of these things, but I don't remember doing so. I decided after much angst to get a 2nd opinion from a dermatologist, but I never went. In the interim 3 months until I could get an appointment, I found a therapist, and my anxiety level went down, and I assumed that it was my anxiety causing me to second guess my family doctor, and rather than risk more humiliation, I canceled my appointment.

For the next 5 years, I kept checking the bump. It didn't change or get bigger. It just kept bleeding and scabbing. I'd go as long as I could without touching it at all, and feel sinking disappointment when it was still there. Finally, I decided that I wanted a second opinion, that it was ok to want this, in spite of my health anxiety history. I'd done massive research, reassured myself that I had very few risk factors. I was young, stayed out of the sun, and the bump wasn't exposed to the sun anyway, hidden in the curve of my ear, but I realized that my research couldn't diagnose it, and the research was sucking up my time.

I went to dermatologist who said, "I don't know what this is. But it's kind of odd and I'm going to biopsy it." A couple days later she called me to say it was Stage 1 Squamous Cell Skin Cancer, and that I needed to have it surgically removed with Moh's microsurgery. She was truly surprised that it was cancer. It's an odd location, and I have very little sun damage. Every follow up appointment she tells me what a freak occurrence this was.

My OCD was all over this in a flash. "See I saved your ear! You have me to thank. Keep obsessing. Don't let up." But after careful thought, I know that it wasn't my obsessing that protected me. My all-or-nothing thinking, common in OCD, said "I must always be right about my diagnosis before I go to the doctor or I am defective. Just keep researching."

It was my struggles with OCD in the past that made me second-guess my decision to get a second opinion. I felt I wasn't reliable, that in fact I was crazy. Part of being human though, is not knowing exactly what is happening in your body, and guessing wrong. And doctors, being human, sometimes assume that anxious patients don't actually have anything wrong with them, even when they do, and there is research that family doctors aren't necessarily good at identifying non-Melanoma skin cancers. I haven't researched my ear lately. The health anxiety kicks up every so often and insists I need to research, but research wouldn't have saved my ear. That is an illusion.

(Partially) Unhelpful Strategies for my OCD: Brain Lock

I read Jeffrey Schwartz's Brain Lock: Free Yourself from Obsessive Compulsive Behavior 8 or 9 years ago. I appreciated the author's understanding of that deep rooted dread that can come with an obsessive thought, and the urge to do a ritual to make it go away. Schwartz is a psychiatrist at UCLA, and a proponent of Cognitive Behavioral Therapy. His method consists of four steps:

• 1. Step 1: Relabel “It’s not me – it’s my OCD”
• 2. Step 2: Reattribute “Unlocking Your Brain”
• 3. Step 3: Refocus “Wishing Won’t Make It So”
• 4. Step 4: Revalue “Lessons Learned from OCD”

Step 3 had the most value for me, in that refocusing meant acting against my ritual of freezing and doing nothing else but "figure out" my obsessive thoughts by actually doing something relevant to my life for 15 minutes. Unfortunately, the revaluing step was harder than it seemed. My OCD was very tenacious and good at constantly questioning whether what I was observing was actually OCD. It's like those Russian nesting dolls, one inside another, inside another, inside another.

Ultimately, part of what worked for me was using Grayson's method of listening to scripts I'd recorded of all that I was afraid of, while refocusing and doing things that I valued, and practicing my ability to live with uncertainty. Schwartz appears to expect that I can become very certain "It's not me, it's my OCD" when in fact the OCD continually questions this.

CBT: Emotional Reasoning

Emotional Reasoning means assuming that if something feels a certain way, then it is a fact. If I feel bad, then I must be bad. Or this exposure feels dangerous, therefore it is dangerous. CBT includes identifying a range of thought distortions, including Emotional Reasoning, and it's the hardest one for me to deal with.

I tend to feel defensive when Leonard says I'm doing this, but he's always careful to emphasize that it's not pretend, that it takes bravery to feel that fear and still choose to do an exposure.

Right now I feel stuck. It's Monday afternoon, and I've been websearching. My shoulder hurts. I've sidetracked into many useless links, and I feel contaminated, as if once I start searching, the whole day is lost, cannot be repaired or changed. OCD in its self-replicating mode likes this feeling.

Finding a Good Therapist for OCD In US and Canada

The International OCD Foundation(IOCDF)has an an OCD Treatment Provider List for the United States and Canada. There is a dearth of qualified Exposure and Response Prevention(ERP)/Cognitive Behavioral therapists, and it can be frustrating to find effective therapy, but this is the place to start.

What to look for:

• Behavior Therapy Training Institute(BTTI) faculty
  
• Graduates of BTTI
• If they are a graduate of BTTI and have a website, check to see if they mention ERP at all. Some take the training, but their sites show no trace of it.
  
• Specific mention of ERP in their listing
  
• Cognitive Behavorial Therapy(CBT) in combination with ERP
  

Keep in mind that this list is made up of therapists who requested to be on it, and there is a disclaimer that the IOCDF does not screen or research any of the therapists, but I do think it increases your odds of finding someone who is well versed in current treatment.

Related Link:
Tips on Finding a Therapist from Austin OCD Center
Finding a CBT Therapist

Ritualizing in my Head: Freezing

The snail in my last post made me think of another creature, the rabbit. I read the newsletter of the International OCD Foundation for 5 years, and though there were many accounts of ERP working, it always seemed to be for people who had physical rituals. Washing hands. Counting. Reciting Prayers. I didn't think I had any rituals. It was all thoughts going on in my head, just obsessions.

Once I started working with an ERP therapist, I began to realize that one of the ways I tried to make obsessions go away was to freeze like a rabbit. If somehow I stay still enough, and avoid going on with my day, or my life, then I can make the anxiety go away. The very thought of carrying on sent a shot of of anxiety pumping through my veins.

This is where I ran into difficulty with Cognitive Behavioral strategies. I joined an anxiety support group in graduate school, and the psychologist in charge introduced us to ways our thoughts can be distorted, like "all or nothing thinking," or "emotional reasoning." We were to fill out worksheets identifying our thoughts and disputing them. At first this was a relief to know there were others who had similar ways of thought, that I wasn't completely alone in this, and that perhaps being able to label the thoughts would help them go away.

But as with much in OCD, this wasn't enough. It was as if I needed to freeze like the rabbit, hoping to fool the predator. I would fill out my worksheet, get a moment of relief and then try to hold my thoughts still and prevent them from spiraling out again into anxiety. OCD wanted absolute certainty that a feared consequence won't happen. Even the slightest chance of a catastrophe and the OCD wanted to gnaw at it and figure it out, and my goal was to prevent this exhausting process from happening, compounded by an OCD perfectionism that demanded I dispute the thoughts "perfectly" and got into an existential debate about which thought to start with and making sure I got every single one.

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Ritualizing in my Head: Retracing