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Mastering Ocd: The Five Principles & Five Keys
| Posted on June 28, 2016 at 8:22 PM |
THE PROBLEM OF OCD Obsessive
Compulsive Spectrum Disorders (OCSD) including OCD, Asperger’s Disorder,
Tourette’s Disorder, Hypochondriasis, Compulsive Hoarding, Trichotillomania,
and Body Dysmorphic Disorder are chronic and often severely handicapping neuropsychological
problems. Studies suggest OCD itself is in
part genetically hard-wired into the brain (specifically the cortical-thalamic-striatal
pathway within the basal ganglia) at birth, and its activation and expression can
be affected by personality factors, life stress, immune system changes,
hormonal fluctuations, weather, diet and many other factors. For most patients a variety of lifestyle
changes and treatment interventions are necessary in order to reduce intrusive
obsessive thinking and compulsive behavior as well as heal the depression which
often accompanies OCD. We can then move
on to restoring self-care, relationships and healthy lifestyle patterns Without taking the risk of
exposure to feared situations it is impossible for any of us with OCD to really
progress in the healing process.
However, when we do so – as noted above - brain imagery studies have
shown us there is actual functional and
structural healing which takes place in the cortical-thalamic-striatal
region of the brain, something that is impossible to produce through any other
method - including medication. Even if
we have thousands of triggers for our OCD, because all of those triggers come from the brain, when we focus on
one mastering one ritual through behavior therapy this heals the brain. This
brain change that radiates out to ALL the rituals, weakening them (since ALL of
them come from the same brain). Thus,
some triggering situations will simply fade “on their own” with the result
that, in the end, we do not have to deal with all our symptoms! In general in order to master
OCD we are confronted with two tasks (1) Creating behavioral exercises (usually
along with a coach or counselor) designed to master the OCD and , (2)
Developing our ability to confront and refuse to go along with OCDs demands as
we run into them during daily life. In
our first main task we must design and carry out exercises which
allow us to get close to a feared experience, thought or situation. We then move on to habituate to the resulting
anxiety by refusing to act out the rituals which we would normally use to
dissipate the anxiety. In other words we come into contact with the thought, situation, person, or object we fear and remain in contact with thefeared stimulus long enough for the
brain to habituate to the stimulus.
This feels much like jumping in a
cold lake of water and staying in the
water long enough for the body to become accustomed
to it. Brain imagery studies have shown
that by using this procedure we can not only change the biochemical functioning of the brain, but also to some extent
regrow new neural pathwaysaround the OCD! This therapeutic process is
called Exposure and Response Prevention
(or ERP). When conducting ERP we utilize the Five Principles of ERP-CBT outlined in
the box on this page to carefully construct ERP exercises which are both
tolerable to the person and effective in causing habituation to the feared
stimulus. In counseling ERP is often
rounded out by the inclusion of other specialized exercises such as the
Over-Valued Ideation (OVI) Exercise, Attention Training and the Multisensory
Massed Imaginal Exposure (MSMIE) Exercise which are discussed elsewhere in OCD
Recovery Center material. Let’s discuss in detail the 5
PRINCIPLES for developing - ERP / CBT exercises. PART ONE: THE
5 PRINCIPLES FOR DEVELOPING ERP / CBT EXERCISES PRINCIPLE I: SAFETY / TRUST When we first develop an OCD fighting
exercise a measure of trust is essential.
Paradoxically, this is often also the time when, thanks to the lies of
the OCD, our trust is at its lowest ebb.
We must work hard to overcome
our fear and develop trust. Primarily
trust that the exercises our ERP/CBT counselor is giving us are safe, but also trust
in a higher power, the universe, destiny, or life itself. The well-know “Serenity Prayer”
exemplifies this Key: “Grant me the serenity to accept the things I
cannot change, the courage to change the things I can and the wisdom to know the difference.” We
must develop trust that we cannot
control everything (actually most things) in life. Compulsive rituals, on the
other hand, are designed to try to
control what cannot be
controlled. Yes, one may choose to brush
one’s teeth in order to prevent cavities, but repeatedly placing our toothbrush
in the holder seven or fifty-seven times will not prevent AIDS. So, while riding out the anxiety arising from
ERP, the OCD sufferer is encouraged to again and again remember to let go of
what cannot and should not be controlled.
In regards to designing ERP
exercises, your counselor is charged with the responsibility of keeping you
safe. It is your counselor’s job to
design exercise that do not exceed what would be expected of the average
person. ERP exercises should not cause
harm, or panic (though they may cause fear of harm!) PRINCIPLE II: INTENSITY OF
EXPOSURE Trusting in our ERP/CBT
counselor, and trusting ourselves to let go of our attempts to control the
universe, we begin creating Exposure and Response Prevention exercises. As we do so, the first essential element we
must include is a manageable level of challenge. In any OCD fighting exercise it is important
to make the experience of the stimulus (e.g. the level of anxiety it generates)
manageable. Most OCD sufferers have a
variety of compulsive behaviors they perform on a daily basis. Some, if stopped, would result in
overwhelmingly intense anxiety leading to panic and an increase in future compulsive rituals. Other rituals carry with them only very mild
anxiety and can be fairly easily eliminated without undue stress. In choosing which rituals to confront it is
wise to make a list of all rituals and then rate them from highest (“100”) to
lowest (“0”) in terms of the anxiety that would be generated if the behavior
were stopped. Then rituals achieving a
rating of 25-75 are selected for ERP/CBT.
If we stray outside this 25-75 anxiety ranger
we run the risk of: triggering panic, being unable to do the exercise, being
unable to resist neutralizing anxiety caused by the exposure, and reinforcement
of target obsession. It is
better to choose an exercise that fosters less anxiety and is manageable
without performing a compulsion than choose a more difficult ERP exercise and
later give in and neutralize the anxiety. In order to adjust an experience to fit within the 25-75 range we can:
(1) Change the choice of target we are working on or (2) Change how target is experienced by (a) Adding
or removing mediators (e.g. wearing gloves), (b) Adding or subtracting anxiety
reduction techniques, (c) Adding or subtracting reassurance or modeling, (d) Increasing
or decreasing duration of exposure or physical distance. For example, we might choose
to modify the strength of the stimulus/situation. For instance, one could spend only a few
minutes by a trash can instead of an hour, or wear gloves while pumping gas, or
ask someone to do the behavior first.
All of these are “mediators” which will titrate the exposure to a
manageable range – much as medication is titrated so that the patient will not
get too much or too little. This allows
us to hit the “therapeutic window” at which the exposure does the most good
without overwhelming the individual. PRINCIPLE III:
NEUTRALIZATION / RESPONSE PREVENTION Once a ritual is selected and
we refuse to perform the behavior (or thought) in spite of the urgings of the
OCD, a surge of anxiety will be
experienced. The brain has sent an (erroneous) alarm message and we have
refused to respond! As far as the brain
is concerned a state of emergency exists and it will “warn” you by sending
anxiety signals throughout your mind and body. It is crucial to remember that these
anxiety signals will always recede if not
acted upon - the anxiety will always go down! Often it will dissipate within 15 to 20 minutes, but even if it continues into the
following day it will go down! But only if we resist the compulsive ritual
our brain is demanding. This is what is
referred to as “resisting neutralizing”. Basically we are refusing the
OCD’s commands not once but twice. We
refuse to do the initial compulsive behavior (checking the stove) and then we
stand our ground in spite of the anxiety we feel and refuse to perform a
compulsive neutralizing behavior (calling our spouse to ask them to check to
stove). This process takes immense
strength, but does get easier as time goes on and then eventually results in more
and more compulsions being resisted. People with OCD are generally
above average in intelligence. We will therefore
have both primary and secondary rituals
for relieving anxiety. For example, we
can wait for long periods of time before performing a compulsion so that we can
fool ourselves into believing it is not connected to the initial stimulus
exposure. Also, neutralizing strategies
can be very, very subtle such as a blink, a head shake or thinking about a
color. It is essential to realize what neutralizing strategies are being
employed and to stop them. Neutralizing
strategies will always short-circuit the treatment process if allowed to
continue. Anxiety checks allow us to monitor our anxiety
level, see that it is indeed dissipating, and helps us to view the process in a
more detached, clinical way – seeing the OCD for what it is, an error message
from our brain. We must simply allow the
anxiety to be present like energy passing through the body and do “anxiety
checks” every 5 minutes. Observing the anxiety level decreasing in this way provides
strong encouragement. . Persist in refusing the ritual until the
anxiety dissipates – however long this may take. Once the anxiety does begin to reduce it is
essential to avoid the temptation to perform another ritual to “un-do” the
exposure. Like aerobic exercise, which must be done for a certain length
of time in order to have cardiovascular benefits, one’s anxiety level must
have decreased by at least 50% before
any positive benefits will accrue. It is
tempting to refuse a ritual initially, but then go ahead and do it in a little
while. This will only provide the OCD
with what is known as “intermittent reinforcement” – a pattern certain to encourage the OCD to continue generating demands
for new rituals. It helps greatly for
the patient to take note of their anxiety level (0-100) every ten minutes or so
along the way. Observing the anxiety
level decreasing.g provides strong encouragement to continue to refuse rituals. It is important that we maintain awareness of the anxiety by
doing “anxiety checks” every five
minutes until the anxiety has dropped by 50% from its initial strength. At that point the individual can go on about
their daily activities without needing to maintain awareness of the
anxiety. It is important to remember
that anxiety may show itself in thoughts, feelings, physical reactions and, or
behavior. Each individual will be unique
in their pattern of anxiety reactions and it may help to identify one’s specific
anxiety symptoms prior to engaging in ERP.
In this Principle also slogans, reminders and
sayings such as “Oh Really”, “Flavor Of The Day”, Questions will also tend to
short circuit the OCD. Saying things
like “Thanks For Sharing”, “I don’t know”, or “Whatever” in the face of an OCD
situation are extremely helpful. By
leaving things uncertain we short-circuit the OCDs desire for absolute
certainty and perfect safety. They help
us to break the illusion the OCD creates that it is real and must be
obeyed. Slogans remind us of the truth –
OCD ALWAYS LIES!” PRINCIPLE VI: SATURATION /
HABITUATION PRINCIPLE V. DURATION / HABITUATION I once had the pleasure of working with a woman
from Belgium who was obsessing about gasoline.
Once a month she would bravely drive to the gas station and, in a state
or tremendous panic, pump a full tank of gas.
She then drove home and washed and scrubbed her body the remainder of
the day. She was being tremendously
brave, but her OCD was getting worse.
One of the first things she and I did together was to have her touch a cotton
swab on the gas can her husband kept in the garage and touch the swab lightly
on one wall in each room of her house.
Her OCD began to get rapidly better. The principles at play here are those of saturation and duration. In order to create change in the brain we
need to expose ourselves to the feared stimulus more than just once a month –
in fact quite regularly! This is similar
to medication – one dose of an antibiotic will not (usually) be enough. We must take the medicine on a regular basis and we must allow it to saturate the infected areas of our
bodies. Our woman from Belgium got
better because her brain was continually
exposed to the gasoline at a manageable level so that she did not feel an
uncontrollable urge to neutralize the anxiety with a washing ritual. Saturation of the environment with the
stimulus for an extended duration cause the brain to heal and build pathways
around the “damaged” OCD circuitry. PART II:
THE 4 KEYS FOR MASTERING OCD
EPISODES (OR CONDUCTING ERP-CBT EXERCISES) Once we have designed ERP-CBT
exercises using the Five Principles our
second main task is to learn how to
master the OCD as it shows up during daily
life. It is one thing to participate
in a controlled exercise designed by a counselor to habituate ourselves to our
fears, but quite another to refuse to give in to OCD “hits” that pop up –
sometimes by the thousands – during the course of an average day! We must learn to negotiate our way through the
often confusing and usually terrifying act of turning to face one’s obsessions while
not succumbing to the urge to neutralize the anxiety through rituals or
compulsions? Here again, having a structured plan of
action (or non-action) is essential. Frequently
OCD sufferers will report that car accidents, hurricanes, earthquakes, public
speaking, near plane-crashes and even armed combat and the like are not nearly as terrifying as confronting an
obsession. This is because obsessions
are generated directly from the brain! If
we were to put a wire into the amygdala area of your brain and turn on some
electricity we can generate much more fear than we can asking you to walk
through a mind field or jump out of an airplane. It is precisely because it is so difficult to
refuse to perform obsessive-compulsive rituals that it is essential to have a set
procedure for doing so. At the OCD Recovery Center we usea specific
5 Key
procedure for walking through the anxiety mine-field Self-Directed Exposure and Response
Prevention (SD-ERP) These 5 Keys,
if followed closely, will take an OCD sufferer step-by-step through the flames
of anxiety that can seem so intense. It
is recommended that the 5 Keys be
applied consistently day after day until they become second nature. The Keys
have been given short labels to make them easier to remember them in practice. KEY I: IDENTIFY Our first task when confronted with a
situation where our OCD is stimulated is to recognize that the urge to perform
the obsessive ritual is in reality a faulty brain message not a real danger. We must concentrate our awareness on what’s happening - on the obsession / ritual - long
enough to truly and clearly see and feel it as just OCD and not a “real”
danger or issue. Several strategies can
help with this: (1) Asking “what would a person without OCD do in this
situation, (2) Slowing down and focusing strongly on the real world around you – NOT on the thoughts going on inside you.
(This is known in Zen Buddhism as “bare attention.”), (3) Placing trust
in a higher power, the universe, destiny, or life itself – realizing that
rituals / compulsive behaviors are not a way to control outcomes in life,
(4) Repeating to oneself slogans, sayings,
or reminders (such as “You can’t put out fire with gasoline!”) that pull your
attention out of the “OCD Quandary” (“Should I?”, “Shouldn’t I?”, “What if?”)
to see that OCD is not real, there is no decision to make, you are not in
danger, and life just is what it is. Regarding slogans, sayings and reminders, it
is particularly helpful to write down or record these so that they are outside of our own thoughts. Since OCD happens inside our mind seeing,
reading or hearing the truth about OCD from outside
ourselves (even if it is we who created the media) is very powerful. In Key 1 we remind ourselves that the urge to perform an obsessive
ritual is in reality a faulty brain message.
Obsessions are thoughts that have gotten stuck in our awareness. If we could eliminate our thoughts (or even
control them) we could theoretically eliminate OCD! This in turn advises us that our job is not
to “get the OCD right”. Instead we must
learn NOT to “dance” with the OCD.
Dancing with OCD only leads us to become more and more stuck – like a
fly on flypaper, or a camel in quicksand.
We must refuse to play OCD’s thought games, or figure it out, or do what
it tells us to do. As with so many things related
to OCD, the success of Key 1 relies
on brain science! There are two
directions we can turn our mind’s focus – inward or outward. When we are listening to OCD we are focusing inward.
The more we pay attention to the OCD – trying to get all our rituals
“right” the more we tune into our inner world – and the more the OCD part of
our brain heats up. When we focus outside ourselves on our environment,
and our bodies, we shift our consciousness to an entirely different area of the
brain – a non-OCD area! It is this
critical shift from inward to outward that breaks the spell of the OCD. We realize that we have OCD we are not the
OCD! KEY 2: DEFY With a clear awareness that “this is just OCD” it becomes easier
(though still often immensely difficult) to refuse to do what the OCD is asking
us to do, think, or say. In Key 2 we simply “just move on” with
whatever activity we were planning to do when the OCD distracted us. We do NOT do the “protective” ritual that the
OCD is telling us so strongly we must do! This is the simplest step,
but by no means the easiest. I worked
once with a combat hardened Airborne Ranger who reported he would rather be in
battle “any day” than have to deal with OCD.
Why? Because the fear our brain
can generate goes far beyond any fear that situations and circumstances outside
of us can stimulate. Fear, after all, is
a chemical response in the brain. There is a saying that we do not
find our courage before we do a
frightening thing – we find it because we did
the difficult thing! So it is that we
must work very hard to defy the OCD – to refuse to believe that what it is
telling us – in order to find our courage.
There is no ritual that must be done to prevent whatever catastrophe the
OCD promises will befall us or our loved ones.
It is all just an illusion and this will become apparent after we defy the OCD! The anxiety will be great, but it will not last. You are doing the right thing to resist OCD
and there will be a benefit down the line as you brain begins to heal and
recover. KEY 3: UNMASK Our next task is to mentally unmask
the OCD – seeing it for what it really is - an erroneous alarm message from the
brain. This is similar to what we did in
Key 1, but we are now further along in the sequence of dealing with the “hit”
from the OCD. As we feel the
anxiety resulting from our defiance of the OCD the heightened anxiety tends to
re-cloud our thinking - OCD’s lies become even more believable! Punching holes in this believability is our
most essential task. We must use all our
mental focus to distinguish between the
inner OCD thoughts and the reality of outside experience while continuing
with life. This is the MOST import of
all the Keys because this is where the
real brain change we are looking for happens! It is not enough to feel the anxiety that comes from defying the
OCD. We must also see that the obsessional thought which is so strong right now is
just a lie – just a distorted alarm message from our brain. We can counter this error message by forcing ourselves to separate from the OCD,
disbelieve it, and see through it.
If we can do these two tasks together - (1) Feel the anxiety and (2) See
there is no reason for the anxiety - our brains will be changing. As we unmask the OCD we will be trimming the
“OCD weeds” from our brain garden and allowing the wild flowers of free-will to
grow once more. Often this means actually stopping all activity and
concentrating one’s awareness on what’s happening long enough to truly and
clearly see and feel it is just OCD - and not a “real” danger or
issue. Armed with this awareness it is
then possible to be aware both mentally and experientially that the compulsion
is not a real “choice”, but rather an expression of the obsessive compulsive
disorder. Various slogans and other
forms of self-talk can be used to achieve this end. KEY 4: RESIST In Key 4 we work hard to resist the
desire to neutralize the anxiety using
our typical strategies - ritual behaviors prescribed to us by the OCD. We must hold out, refusing to act
compulsively to relieve our anxiety, while waiting for that anxiety to gradually
fade and our minds to clear from the illusions created by the OCD. Again, normally the anxiety generated by and
OCD “hit” dissipates in 15-20 minutes.
This is why it is essential to tell ourselves “I will not give in and do
the ritual for at least 15-20 minutes. I
can do the ritual later if I just can’t take the pressure.” Likely after 15 minutes you will be looking
back at the OCD hit and saying, “Yup, that was just another error message from
my brain just like all those other times.
I’m sure glad it didn’t go along with it.” CONCLUSION It is useful to note that even
if one gives in to an OCD ritual it is still possible to make it a “win” by
clearly acknowledging that one has had a “slip” and that the OCD has won a
round, but that nothing real has been accomplished or lost. A helpful statement
here would be “I gave in to the OCD and its meaningless!” (instead of “I
protected myself, or accomplished something by doing the OCD compulsion.”) Also, if one gives in to a ritual another
healthy choice would be to find another similar challenge to do right away so
that the OCD doesn’t feel it has had a victory. One caveat here - conducting
self-directed cognitive-behavioral therapy is very, very difficult without a
guide, mentor, counselor, recovery buddy or some other type of individual who
can assist. OCD tends to be
self-perpetuating and it is extremely difficult to (1) separate from the
obsessional thoughts and (2) stay consistent day after day with the ERP
exercises. Like charging directly into
enemy fire, recovery from OCD is a fairly straightforward process – but the
courage it takes to get started and stay the course is often immense. Working with a “recover buddy” or coach makes
the OCD easier to handle and keeps us on track. There are many other helpful
approaches to living with OCD. However,
without ERP/CBT self-help measures (e.g. learning relaxation training, aerobic
exercise, taking vacations) will likely eventually be overwhelmed by the
compulsions and rituals. There are, of course, many
other aspects to OCD recovery which are discussed in other OCD Recovery Center
articles (especially our article on Special Characteristics of OCD) such
as increased needs for reassurance or symmetry, neuropsychological and physical
differences, etc. Of particular note,
OCD tends to increase our “something is wrong” feeling and this easily becomes
a “something is wrong with me” feeling!
We need to be gentle and kind with ourselves. We are trying hard to live with and get
better from a horrible disorder. OCD recovery is not simply
confronting rituals and compulsions. Undertaking
this courageous task leads to all kinds of positive downstream effects such as
reduced depression, increased feelings of self-sufficiency and a reigniting of
our spontaneity and free-will. The
freedom gained through ERP is a precious gift that only a recovering OCD
sufferer can appreciate fully and the self-love which develops along the way is
worth the effort. Special Note: Any discussion which has the words “steps” and “OCD” in
proximity to one another must offer a deep and heartfelt thank-you to Jeffery
Schwartz, MD who developed the initial Four
Step Model of self-directed cognitive behavioral therapy. Dr. Schwartz is indeed an intellectual
“giant” and those of us who follow are fortunate to stand on his shoulders. ------------------------------------------------------------------------------------------------------------ Christian
R. Komor, Psy.D. is a Clinical Psychologist who combines 15 years of clinical
experience treating Obsessive Compulsive (OC) Spectrum disorders with
discoveries from his personal recovery from OCD. Dr. Komor is the author of Obsessive Compulsive
Disorders: A Comprehensive Program for Recovery (2001), The Obsessive
Compulsive’s Meditation Book (2000), OCD and Other Gods (2000),
and The Power of Being (1992) and EarthSpirit! Dr. Komor leads seminars nationally for
professionals on optimal treatment of obsessive compulsive disorders. He is the founder of the OCD Recovery
Center of America based in Grand Rapids, Michigan which offers both
standard outpatient and intensive outpatient treatment programs for the many OC
disorders. For more information, or to
order books, tapes or materials visit The OCD Recovery Center or Komor Earth Images Copyright 2014 by Christian R.
Komor, Psy.D. All rights reserved. |
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