Category: Obsessive-Compulsive Disorder (OCD)

The Anxiety Disorder Game

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The Anxiety Disorder Game

What causes someone to commit so strongly to the need to avoid doubt and distress?

Imagine a man standing in front of an audience and suddenly being unable to think clearly enough to speak his next sentence, finally stumbling through, putting a quick death to his speech and walking out of the room in humiliation. It would be expected that he would worry about how bad the next time might be, even envisioning himself in a repeat performance. Picture a woman on a bumpy flight, unexpectedly becoming terrified of deadly danger, and not being able to calm herself until the turbulence ended. It would be no surprise if she avoided future flights anytime the weather seemed less than ideal. Consider a father suffering from obsessive-compulsive images of choking his infant daughter. That graphic horror would compel any loving parent to avoid being alone with his child.

An almost instinctive reaction to these traumatic events is adaptation, however not all adaptation is psychologically healthy. Unhealthy adaptation could include exaggerated worries, anxiety, and inhibition of the capacity to act on their environment in an attempt to create a feeling of safety or avoid these threats in the future. If these maladaptive responses continue then the person will develop an anxiety disorder. If we look more closely, it seems that many of these same people begin to develop a general maladaptive framework for operating in the world. Safety becomes of paramount importance. The person with an anxiety disorder believes that losing control of their feelings or circumstances can come quickly and easily. Given that belief, avoidance is an easily adopted strategy. When the person with an anxiety disorder avoids, vigilance becomes their primary safety behavior. Once they recognize a potentially troubling situation, they want to end it immediately. If their heart starts racing and their head gets woozy, they fight to get rid of that discomfort as fast as they can. If the discomfort cannot be stopped by escaping, then they begin what they think is a problem-solving process, however this is not problem-solving but only excessive worry.

The goals of worry make perfectly good sense given the crippling anxiety people have experienced. The problem is that this strategy only serves to increase the problems that they are designed to prevent. When we resist the physical symptoms of anxiety, we ensure that anxiety will continue. The adrenals secrete that muscle-tensing, heart-racing epinephrine through the body, the brain matches it, and we will become more anxious.

Using worry to solve problems will backfire. Worry is a problem-generating process since it causes people to think more about how things might go wrong than about how to correct difficulties. “The human mind is built to worry. Worry helps us to prioritize our tasks, and provides us drive to get each task done by kick-starting the problem-solving process.” People who are prone to anxiety doubt that they have the inner resources to manage their problems, so they use worry to brace for the worst outcome in an erroneous belief that they are productively preparing for the negative event.

Two other tendencies contribute to their struggles. Anxious people don’t want to make mistakes, believing they will have dire consequences. They also don’t want to feel any distress, and the goal of the worry is to stop or avoid uncomfortable symptoms as soon as they arise. That message—“don’t get tense!”—is a sure way to create a self-fulfilling prophecy.

All these tactics together become a powerful force structured within a powerful fortress that drives the decisions of anxious people. They follow a belief system—a schema—that tells them how they should respond to doubt and distress. The belief systems of some clients are so strong that they ride roughshod over the therapeutic strategies we employ. No matter what instructions and techniques we give clients, their overriding unconscious and usually conscious, goals are to end the doubt and distress.

Much of my understanding of these drives, to avoid discomfort and seek certainty at all costs, grew out of years of failures. If I began treatment by teaching someone brief relaxation skills, they would incorporate those skills into their strategy of trying to keep the anxiety at bay. If I offered assignments counter to their defensive belief system, clients would not follow-up on the homework, or they would become confused after leaving a session. If I were especially effective in persuading them of the importance of practicing skills, they would simply drop out of treatment.

For over twenty-five years I have gradually modified cognitive-behavioral treatment that included relaxation training, breathing skills, cognitive restructuring and exposure strategies, to address the special issues created by anxiety disorders. By 1992, for instance, I drew on dozens of discrete techniques, some old standards along with some new procedures, to help my panic disorder clients alleviate distress. But as the years passed, I felt that technique alone was insufficient. My experience taught me that if we focus on techniques without first challenging their beliefs, then their fear-based schema will overpower our suggestions.

Personifying Anxiety

Anxiety disorders have a clear strategy to dominate. They condition the person to three contexts: the situation that stimulated their fear, the fear reaction itself, and their use of avoidance as a coping mechanism. The person creates a defensive relationship with each of these: to become doubtful and anxious when approaching that situation, to feel threatened by their anxiety and want to get rid of it, and to avoid when necessary to stay in control. These strategies are incorporated both into the neurology and the belief system of the person. Each interpretation and behavior in response to anxiety is directly linked to this frame of reference. I use a cognitive approach in which most of the therapeutic time is spent addressing clients’ relationship towards the anxiety, not the anxiety itself. My goal is to teach clients therapeutic principles powerful enough to offset their faulty beliefs that they must battle anxiety and must become relaxed again quickly. Clients learn to mentally step back, away from a poor quality interpretation of the situation (“this is a threat”) and a failing strategy to respond to it (“I must stop it”).

In most ways, this approach matches the standard cognitive-behavioral protocol. However, this is also where I begin to diverge from some standard CBT strategies. To win over fearful anxiety, I believe the therapeutic strategy must meet the following conditions.

1. It must be able to compete with the power of fear and distress. This includes creating an emotional shift that is strong enough to match the drama of anxiety.

2. It needs to have a simple frame of reference that makes sense to the client. My most consistent task with anxiety clients is to keep a clear-cut message at the heart of our discussions. The sharper I am about a few points, and the more emphatic I am about using them as guiding principles, the more successful I am at influencing the client’s point of view.

3. It needs to provide a clear system to follow, with simple rules that guide their actions during fearful anxiety. Otherwise, consciousness gets swallowed up by the fortress of conditioning.

4. It needs to permanently influence neurology or, said another way, their physiological reaction to anxiety.

5. It needs to involve tasks that they feel are within their skill set.

6. It needs to help them feel in control instead of out-of-control. Anxious people regard themselves as victims of the anxiety condition. I want clients to feel in charge, to see themselves as the subject, not the object.

7. It needs to be simple enough and available enough for them to utilize during a confusing, anxiety-provoking situation.

Shifting the Client’s Game Plan

Anxiety disorders play a mental game and they create a game board with rules stacked in their favor. Anxiety wants to distract us by getting us to focus on the content and then to attempt to prevent problems being solved within that content area. For instance, in OCD the content is the possibility of causing harm to self or others through carelessness. In generalized anxiety disorder, it is worry about health concerns, money, relationships or work performance. In social anxiety it is the fear of criticism or rejection from others. This is a clever misdirection, since the true nature of the game is the struggle with the generic themes of doubt and distress. The end result is that the actual problems and solutions to the problems that drive the anxiety are not clear to the client.

The disorder only wins if clients continue to play their expected role. If instead they can see the pragmatic opportunities for viewing their anxiety as a mental game, then we can begin to generate a framework to manipulate. Early in treatment I want to accomplish two goals. First, I want clients to recognize this distinction between the content they have been focusing on and the actual issues of doubt and distress that they must address. Second, I want them to take a mental stance and take actions in the world that are the opposite of what anxiety expects of them. “Anxiety wins when clients seek certainty and comfort. “My goal is to persuade clients to go out into the world and purposely look for opportunities to get uncertain and anxious in their threatening arenas.

For instance, learning the skills of relaxation can be a great asset to recovery. But in training to win against anxiety, it is counter-productive to try to stay relaxed. It is best to seek out discomfort. This is one of the biggest early struggles for clients in treatment: to honestly take the stance of wanting to face the symptoms.

Fortunately, I wasn’t alone in creating such a new strategy. In addition to Eastern philosophy and principles of Zen Buddhism, my guides were Victor Frankl’s paradoxical intention, Paul Watzlawick’s reframing, which stems from the Mental Research Institute’s concept of second order change, and Milton Erickson’s fractionation and pattern disruption. Frankl’s work encourages the client to generate the physical symptoms he most avoids. Watzlawick and his colleagues were the first to define reframing as altering the perception of the problem, the solutions and client resources in such a way as to reinforce therapeutic interventions. Erickson’s fractional approach and pattern disruption aim to make small changes in the pattern of client behavior and the external circumstances instead of opposing the behavior and circumstances.

The Moves of the Game

There is an existential game to learn when dealing with anxiety symptoms. People make a judgment that the symptoms of anxiety are unwanted intruders and threatening enemies and they want the trouble to end. They keep hoping that one day they won’t experience any of these symptoms. Thus, they become trapped by their expectations. Existentially, there is no need for such judgment. The symptoms of anxiety disorders can simply exist, without being deemed good or bad. The anxiety disorder wins when clients judge the symptoms to be wrong and to be banished. In order to win over anxiety, they need to start by stepping back from their current experience, observing it and labeling it as acceptable to them in the present moment. Sounds simple enough in theory, and in the end, clients who recover will master this skill. They learn to stop playing the game by anxiety’s rules. But initially it takes all the clever persuasion a therapist can muster to unhinge clients from their old frames of reference.

In Chart 1 you will see some possible responses to the symptoms of doubt and distress. Clients enter treatment in the position of resistance. In their most resistant position they say, ‘This is horrible. I’ll lose if this happens.” Even the stance of “I don’t want this to happen” gives anxiety the upper hand, because the mind and body will move into battle mode. Ideally, if clients can respond by saying “yes” to the encounter, and accept exactly what they are experiencing in that moment then they will be back in control.

But for many, the anxiety disorder has become so dominant that the client cannot make such a shift directly. As they attempt to accept their doubt and distress, they do so in order for that discomfort to go away. They are still oriented in their natural position of resisting the symptoms. They are more likely to say, “Let me try relaxing into this situation, and I hope this works, because I’ve got to get rid of this feeling.” The skills associated with permitting the symptoms to exist often allow the client to slide right back into resisting.

For those cases, the game takes a different tact. We re-direct the attention of clients away from fighting the symptoms and purposely toward encouraging them. They choose to act as though the symptoms are good instead of bad, and something to be held onto, even encouraged instead of rejected. As clients master this game and learn its lessons, they develop the insights needed to shift toward a non-attached relationship. If they can endure the discomfort, they can learn. I created this framework of a game to help them endure and to teach them three overarching goals.

1) Step back and identify it as a game
The first critical move is to step away from the drama, observe the event and name it. In meditation and in moments of relative quiet mindfulness, when the struggle isn’t great, you simply “step back.” You let go of your attachment to the thoughts. With anxiety disorders, in order to step back, clients must be able to label the event as one in which the anxiety is trying to dominate their mind. During threatening times, the drama is often too enticing to easily drop. They have already generated an automatic and rigid label that identifies the situation as one in which they should become aroused and worried, for example, “This is a true threat to me.” I encourage them to replace this with any message resembling: “OK, the game’s on: anxiety’s trying to get me to fight or avoid now.”

This is one of the advantages of the game. By training clients in a specific protocol and by strongly reinforcing that protocol, they begin to look for opportunities to practice and they become more astute observers of these moments.

2) Stand down 

Once they step back, they need to engage in a strategy to convey to their mind that it is time to “stand down.” The body and mind need help in backing away from the fight-flight mode. If, in the face of a threatening situation, they attempt to say, “I want this experience,” then the mind begins to have a choice other than battle stations.

Clients also need to stand down from the ego’s archetypal win-lose predisposition—winning by domination—and replace it by a more paradoxical strategy of winning by manipulating the challenger’s moves instead of blocking them.
Chart 2 details this next set of moves in the game. Resisting will play right into anxiety’s hands as the expected move. Instead, clients begin the process of standing down by using one of two strategies. Each move is designed to embrace doubt and distress instead of pushing them away.

Standing Down–The Permissive Skills

The first level of the game is to allow the anxiety to continue instead of trying to stop it.

This is manifested in the supportive statements, “It’s OK that I’m anxious,” “I can handle these feelings” and “I can manage this situation.” This approach has a paradoxical flair to it that people often miss. You take actions to manipulate the symptoms while simultaneously permitting the symptoms to exist. With physical symptoms you are saying, “It’s OK that I am anxious right now. I’m going to take some Calming Breaths and see if I settle down. If I do, then great. But if I stay anxious, that’s OK with me too.” We attempt to modify the symptoms without becoming attached to the need to accomplish the task. This is a critical juncture in the work and the therapist must track closely the client’s expected move of, “I’m going to apply these relaxation skills because I need to relax in this situation.” No! While it is fine to relax in an anxiety-provoking situation, it is not OK to insist that you relax. That’s how anxiety wins.We reverse a common American catchphrase by saying, in the face of anxiety, “Don’t just do something, stand there!” When enough epinephrine pumps through the body then the brain yells, “Run!” Consciously overriding this impulsive message takes great courage, but pays great dividends. It differs from desensitization where we help the client gradually approach the feared situation under relaxed conditions. Here we confront their instinct to seek out comfort and encourage them to remain physically anxious and mentally as calm as possible. Instead of believing that there is something broken, they simply accept the status quo.

Going Toward–The Provocative Skills

Many people consider acceptance a weak strategy in the face of the fortress of fear that has been built in the mind. They need to shift from the permissive stance (“It’s OK this is happening”) to the provocative stance (“I want more of this discomfort!”). Here they learn to encourage the symptoms instead of just accepting them. This strategy is extreme and can be thought of as fighting fire with fire. Fear is intense and acceptance is soft. Fear will trump calmness and acceptance every time. I help clients shift to an attitude of provocation that is equally as powerful as, and can compete with, fear. I teach them to use their willpower and conscious intention to seek out an even more rapid heartbeat, to encourage their feeling of contamination to grow even stronger, or to hope someone will notice their hands shaking.

Why this line of attack? Because we want to interrupt the dysfunctional pattern in the most effcient way possible. The straightforward way, using acceptance, is not necessarily the most effcient way because it tends to be susceptible to the clients’ dominant paradigm of resistance, for example, “Let me try to relax here and I hope this works, because if I panic that will be awful!” Consciousness only has so much attention at any given moment. During an anxious moment, I encourage clients to commit themselves to play the game, and to focus their limited attention on following the rules: try to get anxious on purpose by encouraging symptoms. If they will bring their attention to the task of encouraging, even cajoling symptoms to become more uncomfortable, or for doubt to grow exponentially, then they automatically withdraw attention from their fearful goal of ending the doubt and distress.

When I suggest homework activities to clients, I use expressions like, “how about playing with this move?” and “perhaps you can fool around with these responses.” I imply that these strategies are malleable and temporary: “What do you think about just experimenting a few times with this move and see what happens? We can talk about it next time.” For some, we will literally play a game in which they score points for various types of responses to their worry or anxiety, or they will have to pay a consequence when they avoid or engage in some ritual to help themselves feel safe instead of threatened. An example of this strategy can be seen in the case of Samuel. One of Samuel’s fears was that he might unknowingly have cuts around his fingernails and cuticles that would expose him to the AIDS virus while shaking hands at work. Throughout the workday he conducted brief checks of his ?ngers. I gave him the following assignment:

  • Go to the bank and get 40 fresh one-dollar bills.
  • As you leave home in the morning, fold them and place them in your left pocket.
  • Each time at work that you compulsively check your fingers you are to move a bill from your left to your right pocket.

This is a simple intervention, but I gave it to someone who was already oriented to the game. He knew that the only way to keep those dollars in his left pocket was to go toward his distress of not knowing if he was being exposed to AIDS. As he began the game, a typical email from him would say, “By the end of the day, I only had $10 in my right pocket!” There was something about adding that “game” that refocused his attention just enough to lower his struggle and raise his success rate.

I hear this from clients time and again: when they focus on scoring points, or avoiding a therapeutic consequence that we create together, they notice that they become less attentive to fighting the symptoms. When they disrupt their on-going relationship with anxiety by struggling to play the game, they spontaneously become more tolerant of the situation and their distress diminishes. Over time, as they learn the surprise benefits of this pattern disruption, they can congruently adopt the permissive style.

As you might imagine, these people are not easily persuaded to really want this experience. However, this is not the point of the exercise. The point is that they try to associate themselves to the task even if their initial attempts are clumsy. Clients can be encouraged to pretend to want their anxiety, like a role in acting class. This is a cognitive skill, so the work is directed to what they are mentally saying during practice. As they try to subvocalize as if they want to increase their doubt or discomfort, they will automatically dissociate from their typical negative interpretations.

If a client has trouble encouraging the physical symptoms, for example, “I can never want my hands to sweat,” then I suggest a minor shift in their focus. Instead of directly requesting physical symptoms to increase, I ask them to request that the anxiety disorder make the symptoms stronger. Instead of saying, “Come on! I really want to faint right now!,” they say, “please, anxiety, make me more dizzy.” This seems to be just enough misdirection and dissociation to make it tolerable to them, and accomplishes the same goal of competing with their resistance.

The central strategy of the game is for clients to want to embrace whatever the anxiety disorders want them to resist. One of the primary ways I convey the logic behind this wanting is by first defining the process of habituation: prolonged exposure to a feared situation, bringing about a significant decrease in fear.

Wanting Habituation

Habituation requires three elements: frequency, intensity and duration. You have to expose yourself to your feared situation often enough or you won’t progress. When you practice, you need to get up to a moderate level of distress. Practicing while you try to keep yourself calm actually slows your progress. Practicing between 45 to 90 minutes seems to be the ideal amount of time according to the research. These three components of habituation guide all homework assignments.

I think there is a fourth element missing: the spirit of wanting to experience what you need to experience. Clients progress much more rapidly when they desire to have the habituation experience. Unless they are seeking and wanting frequency, intensity and duration as they go toward fear, then by default, they will be trying to do the opposite. They hope they don’t get anxious, that the symptoms don’t get very strong and distress doesn’t last very long. This makes no logical sense to me. If frequency, intensity and duration of exposure to distress and doubt are needed for me to get better, then I want to stumble upon a situation which stimulates my anxiety. I want to do that often, and I want my distress to last, and I want the sensations to be strong. These elements create habituation and habituation is my ticket out the door away from suffering.

Cognitive-behavioral therapy does not teach this specific orientation to clients, although I think it should. If it did, it would alter clients’ disposition toward the problem, help to guide their practice, give them motivation and I’ll bet that it would alter neurochemistry as well. Analogously, if we are receiving chemotherapy for cancer treatment, it would be poor therapeutic form to go to each appointment dreading it, despite the fact that the side effects can truly be dreadful. Instead, you should see the chemotherapy as your friend, augmenting your body’s natural ability to heal. That’s good placebo.

The most important benefit of applying the skill of wanting is that it speeds healing by truncating the habituation process. Clients learn rather quickly that if they invest in the stance of wanting, it returns to them the gift of a rapid reduction in their anxiety. They gain insight sooner in the process, after fewer practices and after fewer minutes within each practice. When they apply the skills of the game during practice, they actually have quite a hard time keeping their distress high (try as they might) or having it linger around for those 45 minutes. By paradoxically applying the orientation of wanting, clients have an “aha” experience during practice that brings freedom.

3) Master the skills of the game through applying technique and practicing (or being a “good student of the work”)
I discuss with my clients the idea of “being a good student of the work.” Good students, of course, are clients who commit to following through on a homework assignment, and then work hard to keep their commitment.

One of Moira’s many OCD compulsions involved her needlepoint work. Frequently she felt compelled to tug on the thread ten times as she tightened a stitch. I offered her a new ritual to adopt. Each time she tugged more than once, on that next stitch she was to tug ten-plus-two times (12). The next stitch she had to subtract three to the number, tugging nine times. Ten on the next stitch, add two, and so forth, until she reached one tug. Her ten-tug stitch became a ritual involving 113 tugs in the next seventeen stitches. She hated that! But she did it, because she was a good student of the work. By forcing herself to stick with our little game, she increased her conscious awareness of her thoughts, feelings and urges during the moments just prior to her compulsive action. At the moment of the urge to pull more than once, she became alert to the punishing consequence. This strengthened her ability to turn away from it. Within a week, that compulsion was of her list of troubles.

Skills Meet Challenge

Doubt relates to clients’ perception that their skills won’t match the challenges they face. If their assignment is within their skill level, then they will be more willing to go forward. This usually means we must lower the challenge and offer them a performance goal within their perceived skill level.

If I am an OCD checker, and I think I have just run someone over, I may yet have the skill to resist my urge to turn the car around and check the highway again. But how about pulling over and running around my car one time before I turn around? I can do that. And now I have interrupted the pattern, which provides me an opening for further changes. One day, as I am having the urge to check, remembering that I now must pull the car over and run around it (again), I might spontaneously decide that that is simply too much effort. At that point I will drive on, and thus experience, with little suffering, exposure to my feared outcome without engaging in my ritual.

Score Points! Win Prizes!

The assigned tasks can be so challenging, so threatening to clients’ frame of reference that they refuse to practice. Even if they do practice, their early efforts may give them only small gains. I mentioned earlier that I create a frame of reference of addressing anxiety as a game in which you can score points. For some clients I create prizes as extrinsic rewards in the early learning phase. Sometimes I offer them metaphorical images, for example, “Imagine that if you walk all the way to the back of the store and stay there 10 minutes that I will magically transfer $10,000 into your savings account. Could you do it then? Play to win, as though your life depends upon it.”

Currently, I have a large woven basket full of prizes, wrapped as gifts. In my anxiety group I bargain with clients: “Anyone who completes three practices this week can draw from the basket.” I have been hiding a $5 bill within two of the prizes as an extra incentive. Last month I rewarded the group member who earned the most points over the previous week with her choice among 12 new self-help books.

Recently I have generated a competition in the group during a several-week period. I agreed that for each member who practices at least 3 times I would contribute $5 into a weekly “pot” of money. I devised a point system to be used for every practice session. Each person decides where and how he or she will practice. Whoever scores the most points, wins the pot. The winnings can grow to be $90.

As you review Chart 3, you can see the essence of the provocative game and the weight of each type of activity. These illustrate the goals I want them to set during practice. They reflect the essence of paradoxical action in fearful situations:

In a threatening situation, step back and become an observer of your process, not be 100% the actor in the drama. Decide to be glad about having the doubt or distress. Put a little light smile on your face or in the back of your mind to reflect it. Then, invite whatever struggle you are having, whether physical symptoms or worries, to stay. Work on trying to mean it. If possible, try to strengthen your move by intensifying your reaction. [For example, I offer nine different choices, such as the previously discussed demand that anxiety make the symptoms stronger.] No matter how strong the doubt and distress becomes, you should treat it as if it is never enough. Reward yourself for every minute you actively invite the symptoms to stay or to get stronger. Accept that other people might notice some problem you are having and for extra credit: hope that they do! Then, when you are done with the practice, learn to support yourself. Drop that critical, disappointed voice.Creating the point system has a number of benefits. The client and I establish a broad strategy together that is manifested through specific actions during practice times. But they pick the practice times to apply the skills. They answer the question, “What can I do today to create some strong uncomfortable feelings for a while?” As they act on this choice, they are empowered and feel a sense of control. Once they are in the anxiety-provoking moment, the point system directly guides them to the therapeutic action.

It is poor strategy to get into a threatening situation and then decide how to act. In that setting, they are competing with a well-habituated set of instructions (“brace, worry, and avoid if necessary.”) Clients are much more likely to regress back to their safe actions, or inactions. When they understand the rules of the game and commit themselves to follow those rules, then recall them as they face threats, they have the best chance of winning

Social Anxiety Strategies

Social anxiety disorder gives clients shaky hands, a quaking voice and worry about the critical judgments of others. Here is the role that it expects of the client: to not want the experience, to avoid it when possible, and to try to get rid of it. When choosing to play the game they ask for the opposite of what anxiety expects: they want anxiety to make their hands shake, their voice quake and their sense of threat heightened. Not only do they request those experiences, but they want them to stick around as long as possible! The clients then attempt to exaggerate their wanting of this experience, and might “desperately plead” for social anxiety to generate shaky hands, or to “cajole” the anxiety to make the experience stronger. They can increase their score by hoping that people will criticize their boring talk or question their shaky handwriting. Earn enough points, win a prize! They refuse to play the game that the anxiety disorder expects. They take charge and push that game board away and pull up their own game board of seeking out doubt and distress when anxiety wants them to defend or run.

Julie

Julie decides to practice facing her social anxiety by eating lunch out alone. She walks onto the lunchtime crowd of “Moe’s Southwest Grill” and is instantly greeted by the cooks and other staff. “Hello! Welcome to Moe’s!” they yell, and the other patrons turn to see who’s entered. Julie begins to feel the flush of red rise in her face as she smiles and nods her head in acknowledgement. Then inwardly she smiles and says to herself, “Yes! Another point.”

Here she describes the process. I’ve added my comments in brackets to her key statements.

“I was really nervous walking in there. I felt like everybody noticed that I was by myself. But that was OK, because that was the point of the whole practice. [She is listening in to her inner conversation and she is permitting her feelings instead of blocking them.] Then having to find a place to sit and making that conscious decision: Am I going to sit with my back facing everyone? Am I going to sit and actually have to look at everybody while they look at me? I made the choice to sit and look at everybody while they looked at me. [She is taking control of the situation by listening in on her process and choosing the more intimidating option.] …I reminded myself that the longer I could stay and the longer I could be nervous and be OK with it, then the better it would be for me. [She has adopted a new belief system about her goals in the fearful situation: stay anxious to win.]

“I thought about how I could make it stronger. I thought that facing everyone while I ate would keep the anxiety going. I was just trying to think of ways to keep the anxiety going. [She is actively strategizing how to provoke symptoms as a powerful way to help her stop resisting.]

“I’m not as afraid of social anxiety as a word because I’ve taken social anxiety and I’ve turned it into a person instead of a condition. It’s not a mother, it’s not a father, it’s just this person or this entity and she wants me to take care of myself. She doesn’t want me to be embarrassed. When I do something that she thinks I could not do, she is impressed. I really like that because it is not a judgmental thing. It is like someone saying, ‘You really should wear a jacket, it’s going to rain.’ But you go out there without a jacket and it doesn’t rain, and they say ‘OK, you did it; you’re still a good person.’ So that’s how I’m thinking about it. [She now comprehends that those ogres, worry and anxiety, have been in her life to help her. They just do it in a clumsy way and she has found a better way. Julie will win this game for good.]”

OCD Strategies

OCD wants the person to try to get rid of any doubts about safety and to take any actions necessary to remove distress. Many OCD clients who fear contamination really do believe that at the moment of exposure they must repeatedly wash to save their life or the life of someone they love. Personifying OCD, I emphasize how it needs them to believe the specifics of their fears. Clients who win over OCD will hold fast to the belief that this is an anxiety disorder. As such, their battle should be with the physical symptoms of anxiety and the urge to end doubt. They should by no means battle with the content of the obsessions. It is never about germs or rabies or salmonella. It is always related to the fear of feeling distressed about threat. To play the OCD game clients set the overarching goal of seeking out doubt and distress.

Eventually, everyone in OCD treatment will do exposure (of the feared stimulus) and ritual prevention, which is the standard treatment for this disorder. But modifying the ways clients obsess or how they perform the ritual is the most efficient starting point for many. Starting with small, lower-threat changes allows clients to practice their new skills and experience early success. Instead of not washing their hands at all after they feel contaminated, clients can change how they wash, where they wash, or what they are doing mentally while they wash.

Jai

Jai was living in a residential program for teens. He struggled with about a dozen different types of washing and cleaning rituals, especially when it was his turn to handle the after-meal cleanup. One ritual required that after he was finished with his (thorough) cleaning of the kitchen, he was to squeeze the sponge ten times while rinsing it under running water.

In our first treatment assignment I asked him if he would fool around with the ritual by switching hands each time he squeezed. In this case, Jai got to keep squeezing and keep counting. He simply altered hands, and switching hands was only a minor threat to him. This is what I call throwing the symptom cluster a bone. You leave in place major components of the ritual or obsession, thus lowering the threat level. However, it is still a change that begins to erode the original fortress of symptoms. He agreed to the assignment, and returned the next week to report how easy that task was. I then suggested this further revision: would he be willing to explore his ability to toss the sponge in the air and catch it with the other hand for each switch? Again, he agreed to this small, silly shift and returned the next week reporting no problems with the task. The following week, he simply squeezed one time and set the sponge down without struggle.

Jai’s playful approach to modifying his ritual became a relatively painless means to arrive at exposure and ritual prevention. It served as a building block for some of his more difficult later encounters with OCD.

Jordan

Jordan, a physician, feared contamination with germs that might come in contact with her clothes during the workday at her medical practice. One of her primary rituals was to spray the entire front of her body with ammoniated Windex® as she left work. She used that same Windex® throughout her home when she felt threatened by germs. Ironically, while Jordan obsessed about becoming sick, her husband, who was also a physician in her practice, was developing serious respiratory problems from inhaling the ammonia. Over months, Jordan worked hard to tolerate switching the Windex® to vinegar-based, then to dilute it to a 50% solution and finally to a 33% solution. Each of these steps increased her doubt just enough that she could tolerate it and experiment with the change. Once she implemented the change, she incorporated it into her routine without much struggle.

But we could progress no further with this or the other safety rituals she performed. Jordan was stuck on the content of her obsession: things had to be clean enough. I failed to persuade her that her attention actually needed to be focused on the strategy of confronting doubt and uncertainty.

Vann

Vann came into treatment struggling with OCD checking rituals that lasted up to five hours a day. Often his concern was that he had missed seeing something he should have noticed: new scratches or dents on the trash can, dust particles under the telephone, an inappropriate item in the basement. Other times he checked as a way to prevent a disaster: an electrical cord will be wrapped around the trash can; his son will trip over some item on his bedroom floor; a fire will start in the kitchen or a flood will occur in the basement. Some days Vann would check a particular item over a hundred times.

Our first ploys involved gently modifying his relationship with his symptoms. For instance, he would check the trash can, but only in slow motion, ever so gradually picking it up and unhurriedly rotating it in his vision. Or he would study the telephone, but not allow himself to touch it. These were his first playful explorations into uncertainty and distress. By the sixth session we added a strategy of postponing. OCD would give him the impulse to check the basement immediately. He would choose to wait thirty minutes before he acted on that urge, again learning to tolerate his discomfort. Through this gradual exposure to the principles, by session nine he was able to avoid locking his house for five days.

Here is how he described his progress by session 10:

“In the past I would pull out the backseat of the car, and if there were dirt there, I would have to clean it up. If a bolt was there I would look at it and get stuck on the backseat, focused on that bolt. Now I do this intentionally. I lift up the backseat and try to make something really bother me, try to feel anxious. I feel that anxiety, replace the backseat, shut the back door of the car and walk away.

When I first started walking away I felt really anxious. I wanted to go back and look at something under that seat again. I felt as though I didn’t look at it hard enough and I’d want to look at it again. I would sweat a little bit, my heart would beat faster, I’d become very irritable and I felt very compulsive. I wanted to go check again! But I just decided I wasn’t going to do it. Sure enough, about two hours later the desire went away.”

Vann completed his treatment in eleven sessions over 5 1/2 months. In a follow-up twelve years later, he remained symptom-free and medication-free.

Conclusion

I began this conversation saying that when I work with anxious clients, I keep my points broad and simple and I focus on them repeatedly. My goal is to influence clients’ perspectives and shift their orientation. I encourage you to try the same.

Help clients to turn away from the content of their fears whenever possible. You cannot always ignore content, because clients will be wrapped up in it. But get past content as soon as you can and move into the core themes of people with anxiety disorders: their struggle with doubt and distress.

The central strategy is for them to want to embrace whatever the anxiety disorders want them to resist. They have two choices. They can “stand down” by choosing to let go of their fearful attention and accept the reality of the current situation. This is the permissive approach. When they have completed treatment, this will be their most common response: to say, “I can handle this situation” and to allow their body and mind to become quieter. The other option is to choose to stay aroused on purpose and actually encourage anxiety to dish them more trouble. This provocative choice is an excellent option during treatment, because choice number one is so difficult to embrace during early encounters. Conditioning and a set of false beliefs are calling the shots; they cannot simply relax on cue. Some treatment protocols will suggest that you help them expose themselves to the fearful stimulus and learn that they can tolerate it. I am suggesting that you put a twist on that set of instructions. Help them to take actions in the world that are opposite of what anxiety expects of them. Persuade them to go out into the world and seek out opportunities to get uncertain and anxious in their threatening arenas. This is a shift in attitude, not behavior. The behavioral practice is not to learn to tolerate doubt and distress, it is to reinforce the attitude of wanting them.

Our ultimate goal is to teach clients a simple therapeutic orientation that they can manifest in most fearful circumstances. Early in treatment, however, you will also need to provide a specific system to follow, with simple rules that guide their interactions with fearful anxiety. Using behavioral practice, encourage them to repeat this new interaction again and again, in all their fearful situations.

You can assume that one of the biggest obstacles to success will be poor planning just moments before the encounter. Whenever they wait until they are scared before deciding the best course of action, then conditioning and faulty beliefs will dictate that they struggle or avoid. In that setting, they are trained by fear to mindlessly seek safety and comfort. Before they enter any situation that is potentially threatening, they should review their objectives and remind themselves of their intended responses.

Thinking of their relationship with anxiety as a mental game offers both a broad therapeutic point of reference and specific actions that manifest it. Initially, your skills of persuasion and their belief in you will push them to challenge their faulty beliefs. After that, experience will be their greatest teacher. Once they have acted on these beliefs and gotten feedback during the fear-inducing event, that learning will put the power in their new orientation and it will be self-sustaining. They will then have a set of instructions, such as “anxiety, please give me more” or “I’m looking for opportunities to get distressed” that will point them toward simple choices during difficult times. And they will have a skill set (that I laid out in Charts 2 and 3) that they believe will match the challenge of the situation.

Breaking Down Obsessive-Compulsive Disorder: The Heart of the OCD

Posted on by Psychotherapy.net Team

The Legacy of OCD

When I was in third grade, I was gripped by the fear that my mother would be killed if I didn’t follow orders. From whom and where these orders were coming wasn’t entirely clear, but I quickly learned to obey. Like the main character, John Nash, in the movie, A Beautiful Mind, I was being watched, and everything I thought was monitored for loyalty to the sinister totalitarian state of which I had now become a new citizen. There was no way out.

Every day at the religious school I attended, it whispered in my ear, “She’ll be dead when you arrive home if you think something bad.”

Living each day with a pure heart became a new curse it threw in my face, a way to trap and punish me in the most painful way imaginable. It would take away the person I loved and needed most in the world: the single mother who protected me and the flame of sensitivity within me which the world seemed all too eager to snuff out.  

When the neighborhood kids dared me to throw away my Winnie the Pooh bear all too soon, I foolishly gave in and was heartbroken. The next night, Paddington Bear in his blue duffle coat and red bucket hat appeared on my bed. When we returned from the movies, my mother asked about the hopes and fears of the characters because she could see it still percolating in me. Like a music conductor, she’d encourage me to allow every section of the orchestra of my mind and heart to play out just a little louder, strengthening a confidence in an invisible capacity I could not yet name.

I adored my mother and knew that without her, my sensitivity would be swept away. So, as Abraham did with God in the story of Sodom and Gomorrah, I negotiated with the amorphous all-powerful entity controlling my fate. If I read every word in the prayer book, it might be appeased. If I had an evil thought, I could cancel it out, and if done right, the entity might be mollified, but in the end, the charges kept returning. No sooner was I absolved of a crime I didn’t know I committed when a new trial restarted. The world was full of impossible binds. Death and doubt resurfaced at every turn.

It wasn’t surprising that I developed OCD. My mother had an identical fear of losing her mother at the same age and struggled with contamination OCD, opening doors with tissues and ever ready with rubbing alcohol. “It’s just my craziness,” she’d confess.

One day, a red futon tied to the roof of our car fell while driving along the highway. Pulling over to the side of the road, 10-year-old me peered into my mother’s eyes expecting to find terror there.  

“This stuff, Michael, the big stuff doesn’t scare me. It’s the little things that get me, remember?”

And with a smile, I helped reattach our precious cargo.

My mother was familiar with living an existence as paper-thin as the tissues she carried with her everywhere to ward off germs. Her parents’ marriage fell apart shortly after their arrival in New York from the Middle East via Panama, when her mom — my grandmother — became the main breadwinner and caretaker of the family of four young children. Sensing her fragility, my mother stepped in to minister to her. A highly educated woman now working behind the counter at a department store to make ends meet, and my mother easily noticed the pain — the unspoken sadness, longing, and fear that others hardly detected. Even my mother’s siblings mistook their mother’s desire to have joyful holiday dinners as just another form of control, instead of what it really was: a cry for help. Please eat and show me, not only that you love me, but that somehow God hasn’t abandoned me like my husband. 

My mother stayed close to home, learning to fear rather than crave independence. Without the freedom to disagree or feel anger, her sensitivity became the emotional suture for a constantly bleeding family. In doing so, she lost much of the thread holding herself together. She doubted her own instincts and confidence, even though she had a sixth sense of empathy few recognized as her hidden superpower. English professors noticed it and called on her regularly for her insights in class, but in the real world, she felt unmoored.

OCD emerged as an expression of how precarious the world felt to her. It offered her a blameless way of seeking the boundaries and guidance she couldn’t ask for directly. When OCD dictates something — when it says, “please tell me everything is going to be okay, please wash your hands, please help me right now!” — it allows for an aggressive urgency that’s otherwise forbidden.  

Sound and Fury

As a psychologist, I’ve treated individuals struggling with OCD since my graduate school days. Then, you could find me on the streets of Manhattan touching tissues to doors and diluting them before doing exposure exercises with clients. You’d find me in the library turning over every stone in my dissertation research on what did and didn’t work for OCD.

These days, I get calls and emails from clients around the world who fail OCD treatment and say they’re not encouraged to talk — even with their own therapists — about the deep feeling and fire they experience within their OCD. To attribute any meaning to OCD, they’ve been taught, is to enable reassurance. To envision OCD as anything other than a bio-behavioral glitch is dangerous and foolish. “It takes seventeen years on average to arrive at appropriate OCD treatment, why would you jeopardize that,” say their therapists. But what if, instead, we listened to what burns so brightly inside OCD?

My perspective on OCD is likely to be dismissed as misguided and anachronistic, even taboo. In the OCD community, talk therapy is believed to be unhelpful at best and regressive at worst. A widely circulating meme in the recovery world echoes the mainstream view, inspired from a passage in Macbeth: OCD is “just sound and fury, signifying nothing.” But what if the meaning at the heart of OCD is there and we’re just not talking about it? What if these clients aren’t failing treatment but treatment is failing them?   

OCD is as much about feeling as it is about thought, as much about meaningful self-expression as distracting noise. Hardwired by nature and stoked by nurture, our brains repeatedly throw an unsolvable dilemma that’s trying to communicate something valuable. OCD is both friend and enemy, but we tend to view it only as an enemy because by the time people get help for it, it’s a five-alarm fire. If you look at it with the right eyes — ones attuned to the sparks of sensitivity within it — you see raw potential in it that’s inspiring, sensible, and bold.

I’ve long been one of the few therapists who espouses this unpopular view. When I questioned CBT orthodoxy in training and experimented with integrating meaning-centered approaches, I was asked to turn in my badge. When I suggested that OCD had an upside in a recent Christmas blog — and foolishly called it a superpower — I was as welcome as the Grinch. Recently, though, I’ve been heartened by two exciting developments: Internal Family Systems as a new OCD treatment and John Green’s book, Turtles All the Way Down, an OCD-inspired story recently made into a movie by the same name.   

Meaning Matters

Internal Family Systems is an evidence-based therapy that helps sufferers befriend their OCD protectors. These parts nurture the sides of the self that have been cut off due to trauma like my mother’s or the intergenerational trauma I inherited. The overactive OCD mind perpetually anticipates dangers and buffers feelings of rejection, hurt, sadness, and terror. If these managers don’t succeed, firefighters take over with compulsions. Running the gamut from checking, washing, counting, or reassurance, compulsions provide visceral instant gratification. They comfort with a cost; repetition is the only way to satisfy, though not for long. Any satisfaction you achieve doesn’t last, and it’s never enough.

My mother’s compulsions to wash her hands were frequently triggered after being recruited into carrying too much of other’s emotional mess. With no relationship to help verbalize her profound empathy and disgust for being placed in such an impossible role, her protectors took over. My own terrors were touched off by the adult world coming for my bear again, only this time it replaced the bear with my mother. I’ve worked with clients whose OCD took away their freedom to sing, to take the subway, or to trust their own goodness. Each of them found unexpected ways to link their OCD to a fuller, more coherent story.

In Green’s book, one of the characters questions a scientist who has given a detailed history of earth and life on it. She insists that the entire world is resting on the back of a giant turtle. When he challenges her about what that turtle is standing on, she replies “it’s on another.” Flummoxed about what that turtle is standing on, she replies, “Sir, you don’t understand. It’s turtles all the way down.” This image doesn’t just capture the repetitive and elusive nature of OCD, it speaks to a hopeful afterimage. What if everything you think of as the random chaos of OCD is held up in more creative ways than you ever imagined?

In recovery from OCD himself, Green crafted Turtles All the Way Down to showcase OCD’s characteristic thought spirals and the methodically masterful ways it wears down its main inhabitants and robs them of their agency. OCD is a nuisance to be rid of, not exalted. As an OCD advocate, Green wants us to feel that. And yet, his characters tell another story, centering OCD around its existential heart, a profound sensitivity hardly ever discussed. 

Teenage protagonist Aza Holmes is haunted by the sudden death of her father from a heart attack and OCD jumps in to protect her — IFS style — from overwhelming fears over the precariousness of life. Is Aza really just a fictional character without any volition of her own? Is the 50 percent of the bacterial microbiome that makes up the human body in true control of her? Aza constantly digs her thumbnail into her middle finger to see if she really exists. But no sooner than she is found, she is lost again, spiraling about the possible infection she’s now unleashed.

Aza’s OCD finds an ingenious way of expressing her existential dilemma. Her scab is a brilliant metaphor of the ever-present wound of her father’s death and all of our deaths. Like my own childhood terrors, the relentless question — to be or not be — constantly buzzes in the OCD sufferer’s ear, a fly always just out of reach. As for Hamlet, a broken heart — not a worried mind — is at the center of OCD. Or as Aza puts it: “When you lose someone, you realize you’ll lose everyone. And once you know, you can never forget it.” A broken heart — not a worried mind — is at the center of OCD.


***

It’s been more than 15 years since my worst nightmare came true and I lost my mother to cancer. And yet, in the aftermath, something shocked me in ways my early fears never prepared me for: instead of falling to pieces, I discovered something new in conversations with my mother in my dreams.

I finally get what you meant that day on the side of the highway. Like those turtles, you were carrying the world on your back. The big stuff. You saw that I could do it too and protected that power every step of the way. You knew how to celebrate it as a gift never to be taken or lost. I realized that gift was life itself, and it was the mysterious heart of OCD. It was holding me up better than any of those turtles ever could, and with it, I could carry everything.

Questions for Thought and Discussion

What methods have you found to be most effective in addressing OCD with your clients?

How have you used metaphors in the treatment of OCD?

What do you find to be the greatest challenge in working with OCD?  

The Wisdom of Therapist Uncertainty

Posted on by Psychotherapy.net Team

“Uncertainty is your space for growth.” – Angela, psychologist

Work hours for many are unpredictable. Political divisions, pandemics, and extreme weather add further unknowns to daily life. In an era that challenges mental health, it’s easy to assume that therapists should be pillars of all-knowing sureness.   

One Fear to Rule them All

But growing evidence suggests that practitioners can benefit from leaning into their uncertainty in times of flux. Skillfully accepting and even embracing not-knowing is linked to better mental well-being and improved decision-making in both clinicians and their patients. “We need to help psychologists view uncertainty not as a horrible thing you need to minimize, but as an opportunity to learn and grow,” says Elly Quinlan, a senior lecturer in psychology at the University of Tasmania and a leader in the study of uncertainty in clinical practice.

How humans contend with the unknown is a topic attracting attention in clinical psychology. This critical capacity is measured by gauging people’s “intolerance for uncertainty,” or the degree to which they view unknowns and the unsureness they spark as threatening or merely challenging. (Sample assessment component: “Unforeseen events upset me greatly.”) (1) Importantly, being intolerant of uncertainty is now recognized as a transdiagnostic vulnerability factor for a range of disorders, including anxiety, depression, and obsessive-compulsive disorder. (2) As Canadian researcher Nicholas Carleton writes, this trait (and state) may be the “one fear to rule them all.” (3)

As a result, leading psychologists are targeting uncertainty intolerance as a promising new way to treat many mental disorders. By taking on more unknowns in daily life, patients gain skill at meeting life’s twists with a curious, open mind, rather than fearfully racing to eliminate uncertainty through denial or snap judgment. During one intervention, young adults tried answering their phones without caller ID. (4) An adult learning uncertainty tolerance in therapy challenged himself to delegate more at work. (5) Results are encouraging: in one recent study focused on bolstering uncertainty tolerance, worry and anxiety in people with generalized anxiety disorder fell after treatment to levels experienced by the general population. (6)

Now Quinlan and others increasingly see uncertainty tolerance as a needed skill for psychologists themselves to practice. Psychologists interviewed for a small quantitative study led by Quinlan reported primarily negative responses to situations filled with unknowns, such as an ethical dilemma or the challenge of selecting treatment for a high-risk patient. (7) The psychologists, who had diverse levels of experience, reported anxiety, feeling inadequate, frustration, and anger. Some avoided complex, ambiguous cases or left a client in order to escape uncertainty. “I actually could not resolve that uncertainty, so I shifted the client to another clinician,” said one.  

Such markers of an inability to manage uncertainty are associated with both anxiety and with burnout, conditions that undermine well-being and decision-making skill. In one study of 252 psychologists, their uncertainty intolerance in client care and in daily life predicted burnout (8), a form of exhaustion that up to 40 percent of mental health providers experience today. (9) Uncertainty intolerance is also linked to overtesting, according to studies in primary care medicine. (10)

The Importance of Uncertainty Tolerance

In contrast, psychologists who accept the intrinsic uncertainty of their work and see not-knowing as an opportunity for learning, as discomfiting as that may be, tend to have higher mental well-being. Angela, a psychologist who participated in another of Quinlan’s qualitative studies, advises younger peers to “treasure the darkness a bit. Uncertainty is your space for growth.” (11) Uncertainty-agile clinicians ask, “What is this ambiguity or my uncertainty telling me?” instead of rushing to bury or eradicate the unknown, says Quinlan, whose research has inspired her to assure her trainees that it's okay, and even helpful, to not know.

By recognizing uncertainty as a path to wisdom, providers gain time and space to consider nuance and alternative perspectives. In a speed-driven world where experts are expected to be all-knowing and ultra-decisive, psychologists often “long for the magic wand” of the quick, clear answers, observes educational psychologist Daniela Mercieca of the University of Dundee. But “it is only by allowing ourselves to be uncertain that we are open to shock and surprise … and complexity.” (12)

How can psychologists learn to recognize unsureness as an opportunity? Efforts to map uncertainty tolerance are so new that interventions to teach this skill set to practitioners are sparse in both psychology and in general medicine. One intervention found that training in non-judgmental mindfulness helped trainee psychologists become less stressed by uncertainty. (13) Other studies have shown that exposure to the visual arts or the humanities can boost uncertainty tolerance in medical students. (14) Quinlan plans to begin formally testing uncertainty-tolerance strategies for trainee psychologists in a few years. 

There may come a day when healthcare practitioners will be routinely taught to manage uncertainty as a way to improve their well-being and their efficacy. But until that time, perhaps clinicians can learn from the peers and patients around them who find wisdom in accepting life’s inherent unpredictability and in realizing that at any one moment they might not know.

Recently, two young practitioners found that openly admitting uncertainty in their practice felt unexpectedly liberating. The opportunity arose in 2020 as cognitive behavioral therapist Layla Mofrad and psychologist Ashley Tiplady worked with Mark Freeston of the University of Newcastle to develop a group intervention to teach uncertainty tolerance to patients just starting to receive care for a range of disorders. (15) To model the intervention’s content, they explicitly talked to one another and to patients about the program’s unknowns, ranging from outcomes of this novel treatment to how a tech outage might affect the day’s schedule.   

Most patients who completed the “Making Friends with Uncertainty” intervention showed significant improvements in their anxiety and depression and nearly half became more tolerant of uncertainty. Moreover, the facilitators themselves found that working with, not hiding from, uncertainty improved group solidarity and their own ability to be partners in care. “It’s easy as a therapist to jump into trying to make things feel more certain … we tried to hold back from that,” says Mofrad, adding that this approach returns therapy to its ideals. “The best therapy will always have an uncertain element, and the best therapists are those who will ask questions, be curious, and not stick to a rigid framework.”

Note: All quotes are from interviews with the author unless otherwise noted. Due to an editing error the references below have been updated as of 4/24/2024


Questions for Thought and Discussion

1. What were your impressions of the author’s premise about certainty and uncertainty?
2. How comfortable are you with uncertainty both professionally and personally?
3. In what ways might you carry forward the author’s research in your own clinical work?  


References

(1) Carleton, R. N.; Norton, P. J., & Asmundson, G. J. G. Fearing the unknown: A short version of the Intolerance of Uncertainty Scale. Journal of Anxiety Disorders, 21, 105-117.

(2, 15) Mofrad, L., Tiplady, A., Payne, D., & Freeston, M. (2020). Making friends with uncertainty: Experiences of developing a transdiagnostic group intervention targeting intolerance of uncertainty in IAPT: Feasibility, acceptability, and implications. The Cognitive Behaviour Therapist, 13 (49), 1-14.

(3) Carleton, R. N. (2016). Fear of the unknown: One fear to rule them all. Journal of Anxiety Disorders, 41, 5-21.  

(4) Unpublished material shared with the author by Stephanie Gorka and Nicholas Allan of Ohio State University’s College of Medicine.

(5) Keith Bredemeier Assistant Professor at the University of Pennsylvania Perelman School of Medicine Center for the Treatment and Study of Anxiety, in discussion with the author, September, 2023.

(6) Michel Dugas et al. (2022). Behavioral Experiments for Intolerance of Uncertainty: A Randomized Clinical Trial for Adults with Generalized Anxiety Disorder. Behavior Therapy, 53 (6), 1147-1160.

(7) Quinlan, E., Schilder, S., & Deane, F. P. (2021). `This wasn’t in the manual’: A qualitative exploration of tolerance of uncertainty in the practicing psychology context. Australian Psychologist, 56 (2), 154-167.

(8) Malouf, P., Quinlan, P., & Mohi, S. Predicting burnout in Australian mental health professionals: Uncertainty tolerance, impostorism, and psychological inflexibility. Clinical Psychologist, 27 (2), 186-195.

(9) O’Connor, K., Muller Neff, D., & Pitman, S. (2018). Burnout in mental health professionals: A systematic review and meta-analysis of prevalence and determinants. European Psychiatry, 53, 74-99.

(10) Korenstein, D., Scherer, L. D., Foy, A…Morgan, D. J. (2022). Clinician attitudes and beliefs associated with more aggressive diagnostic testing. American Journal of Medicine, 135 (7); also Lam, J. H., Pickles, K., Stanaway, F. F., & Bell, K. J. L. (2020). Why clinicians overtest: development of a thematic framework. BMC Health Services Research, 20 (1011),

(11) Fewings, E., & Quinlan, E. (2023). ‘It hasn’t gone away after 30 years.’: Late-career Australian psychologists’ experience of uncertainty throughout their career. Professional Psychology: Research and Practice, 54 (3), 221-230.

(12) Mercieca, D. (2009). Working with uncertainty: Reflections of an educational psychologist on working with children. Ethics and Social Welfare, 3 (2), 170-180.

(13) Pickard, J. A., Deane, F. P., & Gonsalvez, C. J. (2024). Effects of a brief mindfulness intervention program: Changes in mindfulness and self-compassion predict increased tolerance of uncertainty in trainee psychologists. Training and Education in Professional Psychology, 18 (1), 69-77.

(14) Patel, P., Hancock, J., Rogers, M., & Pollard, S. R. (2022). Improving uncertainty tolerance in medical students: A scoping review. Medical Education, 56 (12), 1163-1173.   

Mapping the Heart Of OCD: Going Beyond the Conditions We Know

Posted on by Psychotherapy.net Team

“The heart has its reasons of which reason knows nothing.” —Blaise Pascal

Capitalizing on Empathy in OCD Treatment

Some diagnoses are no-brainers when it comes to treatment. Poll any therapist with a pulse and ask them what’s the best intervention for OCD, and you’ll get the same answer: Exposure Response Prevention (ERP).

ERP is a cognitive-behavioral technique whereby OCD sufferers stare down their biggest fears and learn not to blink. Intending to conjure up their personal worst-case scenarios — the terror of harming a newborn child, the yuck factor of hands submerged in an overflowing trash can in Times Square, or entertaining the possibility that they just might be a psychopath — ERP performs an unusual sleight of hand. By leaning into rather than avoiding anxiety, sufferers break OCD’s unruly spell.

Although highly effective at providing relief for symptoms, ERP is a mind and behavior-oriented approach that misses the most astounding feature of the OCD tribe: their enormous hearts. People with OCD are amongst the kindest and loveliest clients with whom I’ve worked.

And it’s not just my own bias, research confirms this big heart. Recent studies found that individuals with OCD show higher empathy levels compared to healthy controls. They shared the suffering of others in both self-reports and in a naturalistic task designed to test empathy in real time. They also reported more distress over their heightened empathy and are more emotionally responsive and attuned to others compared to healthy controls.

Such responsiveness is at the core of what makes therapists so effective, and yet for those with OCD, it misses two crucial pieces: the self-compassion and self-advocacy to counterbalance a weighted-down heart. Therapist burnout shows it’s possible to be too empathic, but have we ever looked at OCD from this perspective? Maybe we should!

A behavioral approach gives little room to map this expansive OCD heart, and it’s a real turnoff. Like the Grinch, many OCD sufferers don’t want to touch ERP with a 39-and-a-half-foot pole. Between one quarter and one half of people with OCD decline ERP, in some cases even before it begins.

I regularly take on the challenge of asking myself as a therapist: what more can I learn about this condition by entertaining something completely different? In the spirit of punk rock, what can I glean if I rebelliously take on the mainstream? With its one gold standard treatment, OCD begs the question: isn’t there more we can do to help OCD sufferers find their voice? Perhaps ERP is so popular that few have the audacity to question it. Maybe, as Pascal instructs, the heart has its own reasons. Such was what I learned with and through Kate.

Kate’s Therapeutic Journey

“I almost cried when I read your blog post,” Kate confessed during our first zoom meeting. A cinematographer based in LA, Kate was fast losing hope that she’d ever get past severe OCD that only relented, ironically, when she was on set. “I always thought that I was failing at OCD treatment, not doing it right. Like, why aren’t I strong enough to just sit through the anxiety? But when I read your work, I felt like treatment was failing me.”

Kate read my unconventional theory that OCD arises from an empathic and existential sensitivity that goes unnoticed and unsupported, and turns in on itself. That enlarged heart capable of so much love is also keenly aware of the chasm of loss set before us all. Is it any wonder that the majority of OCD sufferers worry that death might befall themselves or someone they love? Or that the ritual du jour might somehow stave off what we all wish to control? At its root, OCD is a keen awareness of the fragility of life and the myriad spells and incantations we use to hold on to it at all costs, even if we must lose ourselves first.

“My parents and siblings used to poke fun when I was little when I wasn’t ready to let go of my teddy bear like they all did when younger. I carried her everywhere; she was the sensitive heart nowhere to be found in my house. I hated that I couldn’t let her go, and even until recently, I felt that way about my OCD treatment. Why couldn’t I be fiercer and face my fears and just grow up? Why can’t I even do this ERP thing right?”

Kate felt guilty in therapy, too. She admired the OCD specialist who first gave her a diagnosis and regaled her with the promise of ERP. Finally, there was hope that OCD didn’t have to rule her world. If he had saved her — as she so often felt — why wasn’t she more appreciative?

As we talked together, it became clearer: feeling wasn’t on his radar. Her therapist didn’t listen or seem to care about all that sensitivity, and she felt rejected yet again alongside her teddy bear. “What does it matter what your obsessions mean?” he’d shoot back, as if to say, “get with the program, this approach isn’t going to get you anywhere.”

In conventional OCD treatment, obsessions are just noise in the system trying to distract from the most significant mission: full acceptance of uncertainty and ambiguity. While Kate always wanted to make meaning and find ever more intricate forms for her feelings, her therapist just wished she’d keep working hard and be satisfied with her progress. There was little room for her own authoritative and unique voice, all that good fire in her heart.

Kate could also detect something unspoken in her therapist’s heart: how much his identity seemed tied to one singular truth and how it rattled him to entertain otherwise. She vaguely knew something about herself — how she existed in the world — hurt him. But she never put those feelings into words. Instead, they metastasized into self-doubt, self-recrimination, and shame.

It clocked Kate in the face when she recognized her therapist’s philosophy in a meme widely circulating and praised on Instagram in the OCD recovery world: “OCD is just sound and fury, signifying nothing.” Borrowed from Macbeth’s famous line when the walls are closing in on his murderous exploits and he learns of his wife’s death (ironically, Lady Macbeth with her “out-damned spot!” is one of the most famous contamination OCD cases in literature), Macbeth’s phrase is one of horror, lamentation, and hopelessness. The world is a meaningless, obsessional march of tomorrow and tomorrow and tomorrow, a tale told by an idiot.

“What is wrong with me?” Kate wondered. “I’ve always been a failure in treatment just as in life.”

The middle daughter of a highly educated and successful family of Chinese immigrants to California, Kate constantly found herself on the outside. Family members pegged her as unable to let things go, and though they’d never outright say it, weak for not being able to be more driven and hardworking like the rest of the clan. “Even your work is all just fantasy,” her mother complained.

Kate’s sister had already long moved out of the parents’ house at 25 and was now in medical school, setting sights on buying her first home. Her brother, an IT specialist, always seemed to be able to fix just about anything. Kate was the anomaly, still living at home with her parents and never quite fitting into the alpha-driven landscape of her family’s California dreams.

“Why couldn’t she just enjoy the promise of all that beautiful California sunshine?” her father protested. Kate was always adrift in the riptides of her obsessions, what if she forgot the stove was on, burned the house down, and killed everybody’s nascent dreams along with it?

“It’s like I can never do what the mainstream wishes for me. Maybe that’s why I’ve gravitated to indie films so much. It’s my only refuge.”

“I’d reverse that. The mainstream has never really witnessed your profound heart. You have always tried to accommodate the mainstream — your family, your therapist, the world — but it has come at the price of who you really are. Your sensitivity has always been a part of what has made your vision so clear and full. It’s no accident that your OCD largely vanishes when your sensitivity is prized, as it is when you are working on films and the director gives you the go ahead to command what you need to get the right shot.”

Kate always had a whimsical and keenly observant view of the world, and it showed in her cinematography. She always knew which way to angle the camera not just to get the right light or best composition, but somehow, she evoked things out of objects and people that were somehow right there, but beyond them as well. Her prodigious talent landed her on projects that she most dreamed of; it was also one of the few places where she felt free from obsessional doubt.

“Because your parents didn’t see your sensitivity as a gift, it got housed in your own mind, and you had to protect yourself and them from its power. You sensed so much of what was happening in your environment but there wasn’t a place to communicate that. It becomes wild in our own minds, but we need relationships — and art — to tame it.”

Kate is in Good Company

Together, we joked about how many artists and innovators shared OCD and this unique sensitivity, if you were lucky, found a place to give it creative form. How Greta Thunberg, herself an OCD sufferer, marshals her profound sensitivity to the neglect of an entire planet into fierce advocacy to save us all from extinction. How young adult author and OCD sufferer John Green chronicles teenagers staring down their own cancer diagnosis in The Fault in Our Stars and writes of Aza Holmes, the greatest young adult character with OCD in American literature, in his novel Turtles All the Way Down.

Like Kate, Aza seeks her own center. Is she just a fictional character without any volition of her own? Is the 50 percent of the bacterial microbiome that makes up the human body in control of her? Aza constantly digs her thumbnail into her middle finger to see if she really exists. But no sooner has she found herself than she is lost again, spiraling about the possible infection she now has unleashed. Compelled to drain the pus and blood, Aza is a hostage of her own self-enclosed system of fear, love, and unboundedness.

The heart figures prominently in Aza’s story too. Her father, also a sensitive soul and unrepentant worrywart, mysteriously drops dead of heart attack while mowing the front yard lawn. Just as Kate is so aware of killing everybody’s dreams and truths in her life, Aza shares a moment of clarity with her boyfriend about the root of her OCD: “When you lose someone, you realize you’ll lose everyone. And once you know, you can never forget it.”

“OCD is a sensibility of sensitivity, one that has an exquisite flame for creative possibility but when traumatically misunderstood and misdirected, it burns the house to the ground. If Gabor Mate specialized in OCD (Kate was a huge fan of this rock-star sage) he’d appreciate it with us too. OCD is more than just a biological glitch; nature and nurture are always in conversation, whether we choose to listen. OCD is trying to tell us more than even therapists are ready to hear. There’s interesting music in all that noise.”

Kate was accustomed to having her true interests and concerns fall on deaf ears. Her relationship with this therapist and with cognitive-behavioral therapy itself echoed her ambivalent relationship to her parents: while she was grateful for having been raised and financially supported by them, they minimized her interests as foolish and viewed her obsessions as just more evidence of her immaturity and self-absorption. Without a clear and secure sense of support from these relationships — her parents or her therapist — Kate relied on her own thoughts and rituals to hold her up.

And yet here was the rub! Untempered by any human relationship, these thoughts quickly became savage and cruel, expecting her to be able to live up to what her perfectionistic imagination could dream up: a world of all-or-nothing purity.

Kate suffered from paralyzing obsessions when out in public places, fearful that the looks of others somehow might cause her to implode. Triggered on subways, Kate left the NY film scene for California where she had more freedom to drive solo. But Kate never quite understood why her obsessions centered around this particular theme and not something else.

“It doesn’t really matter,” her old therapist used to say. That’s the trap of it. It wants you to give it attention and believe it has meaning so you’ll keep on going down the rabbit hole. It’s not to be trusted as your friend.”

But Kate, ever-so-fascinated by the motivations of the characters she tracked in the movies she made, knew there must be more. Obsessions had a funny way of both distracting and focusing us on the things we most feared and desired for a reason. Kafka’s Gregor Samsa didn’t turn into a bug just because he had some tic of the mind, but rather because he felt the alienation, oppression, and depersonalization of his family life and modern society combined.

Successfully Addressing the Heart of Kate’s OCD

We worked on a new kind of exposure response prevention, one that dialed down into all of her feelings and associations with her obsessional fear. As we did, Kate became a more sharply drawn character: she was terrified of being intruded upon, judged, and taken over by the needs of others around her. With her big heart, she was so tuned into the unexpressed fears and desires of everyone that there wasn’t enough room for herself. She sensed the fatigue in her parents, their loneliness for their home country, and their overcompensated worries about surviving. They had no idea that internally she was feeling for them, unconsciously trying to imagine every way she could help them control their fate.

She was compelled to avoid any places which might afford too much scrutiny — subways, planes, trains, long car rides— and wisely found the safest place to exist with complete freedom: behind the camera. There, she no longer was the stage for all the unexpressed feelings of others; she could now orchestrate them for her own artistic purposes.

I knew Kate was making progress in our treatment one day when she started our session rather abruptly, “I know you might want to talk more about what we only half-completed last week, but I don’t want to do that. This is what I need today.”

My heart swelled. I loved the grit, fire, and healthy aggression that I knew she needed to have to own herself, even if she risked temporarily losing me. When I expressed this, she was a bit dumbfounded, “You mean, it’s okay for me to ask this? I’m not screwing up your plan?”

“Kate, it’s always puzzled me why Aza Holmes needed to pick at her finger, but only now do I get it. It wasn’t just any finger; it was Aza’s middle finger. She needed to say a healthy ‘fuck you!’ to the people she loved — her mother, her best friend, even her own OCD — and trust that she was entitled to it. That’s what you’re doing now, and I love it.”

For the first time, Kate began seeing something strong and interesting inside her OCD, like the amethyst crystals spied inside a rock kicked to the side of the trail. She wasn’t broken inside, after all. New facets that other treatments said didn’t exist came into view.

Together, we found the heart of it, the mystery that constantly hovers somewhere between life and death, love and hate, and disaster and possibility. Like Aza Holmes, who had lost her father, her boyfriend, and her beloved Toyota Corolla Harold, Kate recognized the biggest truth of all: “To be alive is to be missing.” And yet, it’s in that unexpected place where Kate was found again.

Using Common Sense Problem-Solving and Worry Containment to Subdue Ruminations

Posted on by Psychotherapy.net Team

The Devil of Rumination and Obsessional Thinking

I often wonder how I as a therapist can best help clients who torture themselves by overthinking and over-analysing in a cyclical manner that essentially gets them nowhere. If it is not possible to help them purge themselves of such burdensome thoughts, is it at least possible to help them make peace with the “unwelcomed devil” of rumination?

I’ll start by reframing rumination as the devil we know, which may still remain a devil, but maybe less scary than the devil we don’t know.

Rumination is a form of obsessional thinking characterized by excessive, usually unwanted, and repetitive thoughts or themes that hijack other mental activity and it is a common feature of obsessive-compulsive disorder and generalized anxiety disorder. It is also dwelling on negative feelings and distress, and their possible causes and consequences. Furthermore, the repetitive, negative aspect of rumination can contribute to the development of depression or anxiety and can worsen pre-existing conditions.

Ruminative states, even for non-depressed people, are directly associated with negative affect. In fact, the more clients ruminate, the more they are likely to throw fuel on the cognitive fire, so to speak, and become entrapped in a vicious cycle, making them feel even worse. My experience with these clients has been that they ruminate in all three time zones of their lives — past, present, and future — on events of both real significance and seeming significance.

A method for tackling rumination that I have found to be particularly useful with these clients is to use problem solving, pondering, and positive reflection. If rumination is overthinking a problem and worries related to that problem, it makes sense to take a positive stance and use problem-solving skills to find the optimal solution that rumination seems to seek, and that could put it to rest. Furthermore, problem-solving strategies can be even more effective when they actually aim to resolve the problem the rumination seeks to magically dispel.

Classic problem-solving models in organizational psychology suggest a series of stages in problem solving culminating in the implementation of action, which can help individuals to either confirm that they are moving in the right direction or think about what changes they need to make in their plans — the verification stage. I also believe that linking problem solving and positive reflection with the specific actions can help to enhance clients’ confidence and sense of efficacy and help them to break the repetitive cycle of rumination.

Applying a Solution Focus

Integrating the above perspective into Cognitive-Behavioral Therapy and Solution-Focused Therapy, I may ask my client to identify and engage in a (small and feasible) first task related to the content of their rumination and plan to complete it as soon as they realistically can. For example, if an individual ruminates about their upcoming “job performance,” they could identify one or two minor work-performance-related tasks and aim to complete them initially.

This first step would not necessarily mean that they have found all the answers to their worries, but it would help them feel that they have at least done something, even quite small, which brought them closer to the achievement of their goal (a positive job performance review in this example). Moreover, from a positive reinforcement perspective, they could also plan to reward themselves with something enjoyable that they “deserve to do” (since they will have managed to take some action, instead of overthinking or freezing).

For certain types of rumination (such as work-related stress or perfectionism), I have found this approach particularly useful as my clients find it easy to find a series of actions or tasks that help them develop a sense of moving forward — and slowly moving away from the gravitational pull of rumination. However, there are other frequent types of rumination that, by their nature and content, do not lend themselves directly to interlinked specific actions, such as “is this the right job for me or not?” or for those clients who don’t have the practical or mental resources at a given time to explore how their rumination could be translated to any specific plan.

In such cases, I invite them to “take a break” from their laborious, constant effort to find a “solution,” which would cease the seemingly incessant pressure to ruminate. This suggestion, of course, is often challenging for them as it directly opposes the very nature of rumination — the underlying implicit, irrational belief that “I need to keep analysing a specific concern, until I find an answer or a solution that I am completely happy with.”

The client’s resistance to pause their overthinking may be underpinned by another implicit belief that “there is no way I will be able to relax and find mental peace until I get everything outstanding done and dusted.” This notion is sometimes effective to help clients increase their motivation to fight procrastination and eventually solve problems and achieve their goals. Nevertheless, at other times, it will just not be possible to solve something as soon as possible, nor to even envision the solution — leaving the client feeling even more frustrated, anxious, and predisposed to continued rumination.

In these situations, the biggest trap is not that they will still have “unfinished, disturbing (pragmatic or emotional) business,” but that they will have trained their brain to believe that it is possible not to have any unfinished business, not to have any more intrusive worries and that “when there is a will, there is always a way.”

However, this otherwise helpful and motivating attitude can often just fuel further excessive worry and rumination. The curious question then becomes, “how can the normally reasonable aim to solve problems as quickly as possible become a problem on its own?”

A Pragmatic Approach to Rumination

In my experience, western culture values a proactive, problem-solving approach that rewards and encourages taking responsibility, a sense of agency, and ownership of our lives, as opposed to being passive and reactive. My aim here is not to explore this cultural notion as such (which would entail a much broader philosophical discussion), but rather to highlight its limitations and to reflect on the ways that we can contain our excessively proactive stance, and the worries and perpetuated rumination that often accompany it.

I have come to believe that as important as it is to be proactive and to take responsibility, it is equally important to fundamentally acknowledge that we only have certain emotional and pragmatic capacity at any given time to deal with our goals and our relevant worries. Thus, we may need to decide that we can only deal with just one of our concerns at a time, while we may also endeavour to teach ourselves to tolerate and bracket all other ones.

Rumination by nature “demands” immediate answers and solutions. In contrast, I encourage my clients to allow their intrusive thoughts to emerge and claim their space, while at the same time, challenge them to fight their urge to engage thoroughly with them in-the-moment (which only fuels further and futile rumination). I encourage them to slow down and allow some time to observe their worries as they emerge naturally and unfold in their mind. At the same time, I ask them to make an “appointment” with that urge a few days later, at which time they can, if they choose, respond to their demand for their attention. During that appointment, they can calmly reflect on which of their worries really matter, which ones require more time to ferment, and whether there is any proportionate course of action they can take (or not?) in response to them. When they manage to gain some distance from the urge to ruminate, or from the rumination itself, they may find out that — not surprisingly — several of their worries no longer claim much of their attention.

Of course, this is much easier said than done. Worries are unrelenting. They have their backhanded way of persevering and drawing clients into their dark, seemingly bottomless pit without offering even a glimmer of light or hope that might otherwise offer a solution that feels “good enough,” and without offering the slightest means of escaping their gravitational pull.

An additional strategy I have found useful to help my clients with rumination has been to invite them to implement an easy, positive distraction at the time when their urge to ruminate emerges. This is indeed one of the common techniques, along with other ones such as mindfulness. However, positive distractions seem to be most useful when they are combined with a “reassurance” to our worries that we will indeed come back to them at a more appropriate time, when we will be better prepared and have the mental space to deal with them.

In this context, I have had clients set an appointment with their worries and I actually encouraged them to take this appointment quite seriously. Thus, when clients actually engage in these appointments, they often find that some of these worries have been impatiently awaiting their arrival and are still adamantly demanding their attention, while others have not. At that point, and only at that allotted time, the client is better prepared to address those worries, having built the patience and mental space to do so. As therapy itself is an ongoing process as is problem resolution, clients come to appreciate that it is not necessary to respond to the siren call of worries when they first arise. Pandora’s box will always be there waiting for them in the therapy room, and they will choose when to open it or not.

Most of the above points were at play in the work I have done with one of my favorite and long-term clients. Stuart, as I will call him, was ruminating equally about “small things,” like the slight slope on the floor of his Victorian-age house; and big things, like the dilemma of whether he would ever find a more meaningful job and career. I knew that saying to Stuart something like, “don’t think about this,” would just make him think about these concerns even more.

Instead, I said to Stuart, “you can think about this as much as you want, but could you possibly give up on finding an answer to your worry in-the-moment? And maybe, as you will still be thinking about it, could you also try to do surface research online about any jobs that are out there, that could potentially be meaningful for you in the future?’’ This intervention was a combination of a positive distraction, patience, and looking forward. When Stuart came back for his next session, he told me that even though his ruminations were still there, he was much more able to contain them. Was he then able to “become friends” with them? Well, not necessarily, but by practising to sit with them, slow down, and possibly add a positive distraction in the mix, his ruminations certainly became a more familiar, less scary, and more tolerable devil.

Stuart was a willing worker, as are many of my clients. But it was as important to build a relationship of trust and hope with him as it was to help him build a sense of hope and confidence that he could eventually subdue his ruminations and live freely.

Treating the Compulsive Personality: Transforming Poison into Medicine

Posted on by rezendevknowfully.com

One summer during my analytic training, I committed myself to study, outline, and completely internalize Nancy McWilliams’s Psychoanalytic Diagnosis (1994). The idea that you could be more effective with clients by understanding their specific patterns ran contrary to the anti-diagnosis attitude at my training institute. But it appealed to my eagerness to be helpful.

Not long after I began, I recognized myself in the chapter on the obsessive-compulsive personality. While I didn’t meet the DSM-5 criteria for obsessive-compulsive personality disorder (OCPD), I certainly had my compulsive traits: perfectionism, over-working, and planning, just to name the obvious. McWilliams’ description elucidated who I could have become, had I not had a supportive family and lots of analysis to rein in those tendencies.

But this wasn’t just personal or theoretical. I recognized the collection of traits found in the personality style in my many driven, Type A, and perfectionistic clients working in law, finance, and publishing in work-crazed midtown Manhattan. And I saw the suffering it caused.

The Unrecognized Stepchild of Personality Disorders

Captivated by the subject, I eventually got involved in some online OCPD support groups. There, I read many stories of people who thought they had OCD for years before finally realizing that their entire personality was characterized by compulsive tendencies. They had known that their struggles weren’t just with specific obsessions and compulsions, but that was the only diagnosis they were aware of that was even close to describing them. And in many cases, OCD was the diagnosis a clinician had given them.

This pattern of misdiagnosis became even clearer once I began receiving comments and emails from people reading my new blog, The Healthy Compulsive Project, and my book, The Healthy Compulsive.

While OCPD is one of the most frequently occurring personality disorders of the ten listed in the DSM, it is under-recognized and probably underdiagnosed (Koutoufa & Furnman, 2014). Far too often, it’s confused with OCD by both the public and clinicians. One study indicates that the lack of recognition of the condition leads to a lack of empathy for it (McIntosh & Paulson, 2019). And far more people suffer from obsessive-compulsive personality traits than those who meet the full criteria.

It doesn’t help that it’s ego syntonic not just for the sufferer, but to some extent for our culture as well. Capitalism doesn’t care if you work too hard. According to psychologist and researcher Anthony Pinto (2016), there is no empirically validated gold standard treatment for OCPD. I suspect that this is a function both of our tolerance of it and of the difficulty in treating it.

What’s the Meaning of This?

As I filtered all of this through my training as a Jungian analyst, my curiosity about the underlying meaning of the disorder was piqued. Jung emphasized the importance of asking what symptoms and neuroses were for. What potentially adaptive purpose did symptoms serve in the patient’s life, or for humankind at large? Could there be meaning under something so destructive? Was there some underlying attempt to move toward individuation gone awry?

Looking up the etymology underlying the word “compulsion,” I realized that it wasn’t originally a bad thing. A compulsion is an urge that’s almost uncontrollable. A drive or force. And that’s not all bad. Many of these urges lead to creative and productive behavior. But “before I could find any possible light in the condition, I had to acknowledge how dark it could be”.

The Cost of OCPD

The more I observed the world of the obsessive-compulsive personality, the more I came to see its destructive potential. A review of OCPD by Deidrich & Voderholzer (2015) tells us that people who have OCPD often have other diagnoses as well, including anxiety, depression, substance-abuse, eating disorders, and hypochondriasis. OCPD amplifies these other conditions and makes them harder to treat. People with OCPD have higher than average rates of depression and suicide and score lower on a test called the Reasons for Living Inventory (Deidrich & Voderholzer, 2015).

Medical expenses for people with OCPD are substantially higher than those with other conditions such as depression and anxiety. And the study indicating this only included people who had sought treatment—which excludes the many with more serious cases who don’t (Deidrich & Voderholzer, 2015).

The cost for couples and families is great. People who are at the unhealthy end of the compulsive spectrum can be impossible to live with. They can become mean, bossy and critical, and their need to control often contributes to divorce. Much of the correspondence I receive is from partners of people with OCPD who are at the end of their rope, looking desperately for hope that their partner can change.

Parents with OCPD often place unreasonable demands on their children. This can interfere with developing secure attachment and may also increase the chances of a child’s developing an eating disorder.

It also causes problems in the workplace. While some compulsives are very productive, others become so perfectionistic that they can’t get anything done. Still others prevent their coworkers from getting anything done because their criticism disrupts productivity.

Similar problems happen in other organizations such as volunteer groups and religious institutions. People with compulsive tendencies often become involved in community groups, and they’re so convinced that they’re completely right, and that they should control everything, that they contribute to the deterioration of the organization, partially because others don’t want to work with them (Deidrich & Voderholzer, 2015).

Just as disturbing is knowing of the many personal, community, and cultural benefits that the condition prevents when it hijacks energy that would otherwise have led to leadership, creativity, and productivity. Compulsives can be movers and shakers, but instead they often end up being blockers and disruptors. The people who shape the world are the ones with the most determination, not the ones with the best ideas. And compulsives have lots of determination.

The Adaptive Perspective on OCPD

As I looked more deeply into the condition, I could see that the original intention beneath compulsive control is positive: compulsives are compelled to grow, lead, create, produce, protect, and repair. It seemed to me that the obsessive or compulsive personality is not fundamentally neurotic, but a set of potentially adaptive, healthy, constructive, and fulfilling characteristics that have gone into overdrive.

I’m certainly not the only one to make this observation. A dimensional perspective of personality disorders is gaining momentum (Haslam, 2003). But this viewpoint is still sorely needed for sufferers, partners, and clinicians.

Realizing that evolutionary psychology might provide an understanding of the adaptive potential of obsessive-compulsive tendencies, I contacted psychologist Steven Hertler, who has been on the front lines of thought in this area. His ideas resonated with what I had suspected about the survival benefits of obsessive-compulsive tendencies: the behavior that those genes led to made it more likely that the offspring of those with the genes would survive (Hertler, 2015). For instance, being meticulous and cautious is part of what Hertler (2015) refers to as a “slow-life strategy,” which increases the likelihood that those genes will be handed down.

Most importantly, though, a perspective which highlights the possible benefits of a compulsive personality style has significant clinical benefits. Conveying the possible advantages of this character style to clients lowers defensiveness and encourages change.

There is a wide spectrum of people with compulsive personality, with unhealthy and maladaptive on one end, and healthy and adaptive on the other end. Clients on the unhealthy end of the spectrum can be very defensive about their condition. They tend to think in black-and-white terms, good and bad, and their sense of security is dependent on believing that they are all the way on the good side. This makes it hard for them to acknowledge their condition, enter therapy, and get engaged in treatment. When they do come in, it’s usually because their partner is pressuring them, or because they have become burned-out or depressed.

If we are to help people suffering from obsessive-compulsive personality disorder, we need to find a way to get under their defenses so that they can make use of therapy. When we understand and convey that OCPD is a maladaptive version of something much more positive, we begin to forge a good working relationship.

But as therapists, we should also acknowledge that some individuals are so far to the unhealthy end of the continuum that even if they were to enter therapy, we might not be able to help them. It was important for me, at least, to be realistic, so that I didn’t set myself up to feel that I had failed if I wasn’t able to help someone.

Characteristics of the Obsessive-Compulsive Personality

The DSM-5 says that OCPD is defined by a “preoccupation with orderliness, perfectionism, and mental & interpersonal control at the expense of flexibility, openness, & efficiency” (American Psychiatric Association, 2013). It goes on to list eight criteria; since these criteria are readily available, I won’t list them here. But I do want to emphasize what the DSM-5 (2013) points out in the first criteria: people with OCPD are preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost. I have found this to be a defining characteristic of people on the unhealthy end of the compulsive spectrum—they’ve lost the point of their rules and efforts to control. They’ve lost their original intention, the thing they first felt compelled to do.

I remember being struck the first time I noticed this. A female client was talking about how she had berated some people for not following the rules. It struck me that she was so adamant about the rules that she had forgotten who the rules were meant to help and protect—the very people she was berating.

One goal of treatment should be to help clients recover, or uncover for the first time, the original impulse, the deeper motivation that has compelled them. I may be biased because I practice psychodynamic treatment, but it seems to me that because OCPD affects the entire personality, psychodynamic treatment will be the most effective. I say this because cognitive and behavioral treatments are most effective for very specific issues, less so for the sort of global issues that characterize OCPD.

But those of us who work psychoanalytically may need to budge a little on maintenance of the frame, disclosure, the use of goals, and our reluctance to diagnose. Just as the saying “the only way to peace is peace” goes, “the only way to flexibility is flexibility.” We need to be mindful of our own personal need to control, and a certain rigor that our training may have encouraged: we might think or feel that we are doing the “right” thing by following the rules. But in particular aspects of the work with compulsives, we may gain more through example than through analysis.

Eight Key Points

I’ve found that there are particular themes and tasks that I usually need to work through with compulsive clients over time. I don’t believe that these are unique to OCPD, but rather that they usually require more emphasis than might with other conditions. I outline these below with the suggestion that they be used in a flexible and organic way, rather than as hard and fast steps.

In each of these steps I try to enlist clients’ adaptive compulsive characteristics to foster change.

  1. Create a narrative respecting inborn characteristics. To help compulsives diminish insecurity and develop self-acceptance, “I’ve found that it is important to create a narrative which distinguishes authentic, organic aspects of their personality” from those which were the result of their environment. Compulsives are born with traits such as perfectionism, determination, and attention to detail. They usually like constructive projects, and this can be a joint project that nurtures the working therapeutic relationship.
  2. Identify the coping strategy they adopted. If there was a poor fit between the client and his or her parents, the child may have used their inborn tendencies, such as perfectionism, drive, or self-restraint, to find favor and to feel more secure. Most unhealthy compulsives become so when their energy and talent are hijacked and enlisted to prevent feelings of shame and insecurity, and to prove that they are worthy of respect, inclusion, and connection.
  3. Identify when their coping strategy is still used to cope with anxiety. Recognize if and how they still use that coping strategy as an adult. Most coping strategies used to ward off anxiety will diminish if the anxiety is faced head on rather than avoided with compulsions.
  4. Address underlying insecurity. Question their self-criticism and replace it with appreciation for their inherent individual strengths, rather than pathologizing or understanding them as reactive or defensive. Reframe their personality as potentially constructive. I’ve seen this perspective help many people as they participate in OCPD support groups.
  5. Help clients shift to a more “bottom-up” psychology. Nurture their capacity to identify emotions and learn from them rather than use compulsive behavior to avoid them. Help them to identify and live out the original sources of their compulsion, such as service, creation, and repair, actions that would give their lives more meaning. Help them to make choices based on how things feel rather than how they look.
  6. Identify what’s most important. Most compulsives have either lost track of what’s most important to them, or never knew. Projects and righteousness that they imagine will impress others fill the vacuum. Instead, once they can feel what they were naturally compelled to do, they can use their determination to fulfill it in a more satisfying way.
  7. Identify personality parts. Compulsives try to live in a way that is entirely based on direction from the superego, and they attempt to exclude other aspects of their personality. I have found it very helpful to have them to label the dominant voices in their head (Perfectionist, Problem Solver, Slavedriver), and to identify other personality parts that have been silenced or who operate in a stealth way. Depending on what the client is most comfortable with, we can use terms from Transactional Analysis (Parent, Adult, Child), Internal Family Systems (Exiles, Managers, Firefighters), or a Jungian/archetypal perspective (Judge, Persona, Orphan).
  8. Use the body, the present moment, and the therapeutic relationship. Compulsives rarely experience the present and usually drive their bodies as vehicles rather than nurture them. Bringing their attention to their moment-to-moment experience and using their experience of you as their therapist can help. For instance, bring their attention to tension in their body and, if possible, connect that with any feelings that they have about you. For instance, do they feel a need to comply with you, or any resentment about complying with you?

The Case of Bart

Background

A man in his early forties, whom I will call Bart, came to see me when his wife said she could no longer tolerate his worrying and unhappiness. To his own surprise, he found himself tearing up as he described his life to me. He didn’t do that kind of thing. Ever.

Bart was handsome, fit and bright. Yet he was very self-deprecating.

He told me that he worked in finance and had done well enough to provide comfortably for his family. But his success didn’t register with him at all. He worried about what others thought of him. He feared that people would discover that he was a hoax at his job; he believed his success was accidental and that he could lose it all at any time. At this point in his career, he was just coasting and didn’t find any meaning or challenge in it.

Bart imagined that his family tolerated him only because he provided for them. During our initial consultation, he said he wasn’t feeling bad. But it was clear that he had experienced serious depression in the past, and I suspected that he was still depressed but couldn’t acknowledge it.

His wife was lively, talkative, and highly social, but their relationship was flat at best. He made it a point to say that he did not want to blame her for any of his problems or theirs as a couple. Nor did he want to assign any blame to his parents. Any problems he had were of his own making.

He admitted that he found it difficult to engage feelings. He avoided reflection, journaling, and talking. Like most compulsives, he controlled not just the outer world, but also his inner world. It was hard for him to tolerate uncertainty.

He played organized sports about four days a week, and he had great difficulty tolerating any mistakes on the field or court. He constantly monitored success and failure with a scoreboard in his head. He had quit playing golf because he got too upset when he didn’t play well.

At the end of our initial consultation, I told him that it seemed to me that while he had adapted very well to the external world, he had not adapted well to his inner world. Achieving that would be one of the goals of our work together. I was confident that if he could put the same energy and attention that he had put into career success into his psychological well being, he would see change.

He told me that his impressions of therapy were based on media examples and that he didn’t have any idea how this worked. I told him that I was glad he was asking because we as therapists don’t always do a good job of explaining how the therapeutic process works. I agreed to be transparent about the course of our work, to share how I believed we needed to proceed, and to explain the rationale behind my suggestions. In particular, I would try to be clear about his role in the work.

Narrative

His mother was depressed and a classic martyr. Masochistic, even. She seemed to enjoy her suffering. His father worked as a salesman and was willful, driven, and judgmental. He insisted on success: winning was his religion. For Bart this meant that if his behavior didn’t lead to points on the scoreboard in terms of some productivity or success, it was meaningless. His father said, “it’s good to win.” Bart extended this to “it’s terrible to lose.”

Bart internalized the strategies of both parents, and it caused a terrible conflict: he had imperatives both to lose and suffer (his mother’s masochism), and to win and achieve (his father’s need to triumph). He chose to be more like his father from his teens until he was 25; then he switched and became more like his mother. But he couldn’t let go of the feeling that he should still be winning all the time, in addition to learning, producing, and working all the time. He had lots of “shoulds.”

He had concluded that people want compliance rather than authenticity. He was raised Roman Catholic, and he’d make up things he had done wrong to have something to admit when he went to confession. He told me that he no longer believed in God, so he had to punish himself now. He felt guilty about any sort of self-assertion. He loved post-apocalyptic films because “in that setting, you don’t have to worry about being good anymore.”

Yet Bart didn’t feel that his parents or his environment had any bearing on his current struggles. So I said that the most important thing for us now was to understand how he had adapted to the situation he was raised in.

Coping Strategy

One aspect of Bart’s strategy was trying to control people by giving them what they wanted. Meeting his father’s expectations was only the beginning. Among the four types of compulsives, he was clearly a follower/people-pleaser. He tried to achieve self-acceptance through others’ opinions of him, but it didn’t work, even when he did get accolades.

Another aspect of his strategy was to not depend on others. To do so would rob him of control. It would take time for him to realize that he actually did have social needs, but that, so far, those needs had only gone into impressing others, rather than relating to them. As with many compulsives, Bart felt it was safer to seek respect than to want love.

In his martyr mindset, being a victim implied that he was good. So he often became very negative about his life to prove to himself that he was a victim. He wouldn’t complain verbally to others, but he did need to show himself, at least, how bad his life was. Later he came to realize that his depressed moods were also unconscious attempts to communicate the misery that he could not reveal directly.

He was aware that he had adopted a strategy of planning and perfecting to try to pre-empt the utter self-contempt he unleashed on himself when things didn’t go well. “But why the self-contempt?” I asked. “If I’m self-critical, it will show other people that I won’t tolerate mistakes. But it’s become habitual. I do it even when other people aren’t looking.”

Engaging Feelings

Much of our work involved learning to identify feelings and excavating different levels of feeling so that he could operate from a more “bottom-up” approach. We spoke of therapy as a gymnasium for exercising his capacity to tune into feelings. As with many compulsives, framing our work in terms of a project was helpful in engaging him. I tried to bring attention to what he was feeling in his body and to the present moment.

Most of his feelings were about “shoulds.” Desires were few and far between. Tuning in to desires was a heavy lift for him, but with time he began to be more aware of the difference between acting on fears versus acting on desires.

At times Bart felt like giving up, whatever that might mean. I recommended that he take that seriously but not literally: What is it that you really need to give up? What is the control that you would be happier without?

As he let go of self-control, anger began to surface and eclipsed his sadness and anxiety. Part of him believed that he always did the right thing, and he got angry at those who didn’t. While he was typically self-effacing, it was new for him to acknowledge that in some ways he felt superior.

But we also needed to continue to excavate even more deeply beneath his anger and judgement to see if there were yet other levels of fear or sadness. While it was scary and sad to acknowledge how much was out of his control, it was a relief not to be avoiding it.

When he first came into treatment he had imagined that therapy would remove all his uncomfortable feelings. But with time he came to realize that it was okay to have feelings—sad, anxious or angry—and that he could learn not to amplify those feelings or carry them needlessly. With time, he didn’t need to avoid them so thoroughly.

Identifying What’s Important

Even as he learned to turn his focus inward, he found it hard to articulate his goals in life, career, and therapy. He had lost track of himself and what he really wanted long ago.

Because he had little access to feeling, he was unable to find direction. He obsessed about his job and whether to change companies or even careers. He liked the idea of a new career, especially one with a new identity, but he couldn’t follow through on that. He feared losing the fantasy of what it would be like if he did change.

As he navigated his professional and personal world, I often had to ask him what was most important to him. At first this was distressing, since he had no idea who he was or what he wanted. He was always climbing mountains, but he wasn’t sure whether taking on challenges was something he felt he was supposed to do or something he wanted to do. This skill of distinguishing how something looks from how it feels has been essential to the improvement of most of the people I work with. He couldn’t tell the difference, and we kept revisiting the distinction.

In his efforts to succeed, he’d lost track of why he wanted to succeed. Any sense of fulfillment in accomplishments was replaced by the need to achieve to prove to others and himself that he wasn’t a fraud. Over time he came to recognize that taking on challenges was fulfilling, that he genuinely enjoyed it, and that it was vital to his feeling better. But to enjoy it, he had to let go of using the challenges to prove his worth.

He had similar realizations when telling me about learning: this wasn’t just something he should do to silence his father’s demanding voice, it was something that was very satisfying. He didn’t have to do it, he wanted to do it. And that made it more pleasurable.

We explored his feelings about his marriage. He did value his marriage but was reluctant to depend on his wife: “I’d like to think that I don’t need my wife, but I do. And because I don’t want her to be too important, I don’t take in her support.” This would have made him too vulnerable and would have gone against the masochism he adopted from his mother.

It was a small revelation to him when he was recounting his weekend and noticed that spending time with his son had actually been pleasurable. It wasn’t just a “should.” Noticing this feeling of pleasure was a small window into what was most important for him. “I’ve been putting points in the wrong basket all along, thinking that making money was most important…I have to challenge the idea that piling one more dollar on the stack will make me feel better.”

He came to value more peaceful emotional states—being more present and accepting, and less regretful and judgmental.

Transference & Countertransference

Coming to therapy was not comfortable for Bart, partially because he felt he wasn’t “good” at it. “I remembered that he had quit playing golf because he wasn’t good at it and wondered to myself if the same could happen with therapy”. Still, his ability to speak to me directly about his discomfort was a success. Doing so served as a sort of psychoanalytic exposure therapy, staring down his deep fear of being real and of being known, with the added advantages of eventually understanding the causes and functions of those fears.

He once asked whether therapy was like confession. I explored what it was like in that regard for him and reminded him that when he was young he would make up sins to take to confession. Would he need to do that here? He didn’t think so.

He admitted that he wanted to learn the language of psychotherapy to please me. “Sometimes I tell you what I think you want to hear. I never lie to you, but I do try to figure out what you want.” He felt pressure in the silence to figure out what he was supposed to say. We explored this as a good example of his strategy.

“I’m afraid you think I’m a dick,” he said. “I’ve got so much, what’s my problem? Why am I complaining? You must think I’m just indulging here.” Was this feeling unique to our situation, or was this actually typical of how he felt with most people? He acknowledged that he never felt that it was okay to feel even tolerably accepting of himself, much less feel really good. That would be indulgent and arrogant. And it would invite humiliation.

He had imagined that I would give him a thumbs up at some point, certify him as mentally healthy, and send him on his way. We used this as an opportunity to distinguish what was more important: what I thought about him or how he felt about himself.

Allowing me to know him, and questioning how he imagined I saw him, was a step in the direction of being more open with people in general. Looking for parallels with what he imagined I thought of him, we explored the difference between what he imagined his wife thought of him, and what she really thought of him. As he felt less criticized, anxious, and depressed, she scrutinized him less, and he began to feel more comfortable with her.

“I also experienced my own discomfort with him”. I feared that he would run out of things to say and that I would be exposed as not having anything to offer him. I was not able to work this through completely, but in retrospect I suspect that my fears of being found inadequate were both induced and my own.

He missed a fair number of sessions. Even accounting for the fact that business meetings came up last minute, it still seemed that he avoided his issues at times by not coming. I thought it might be fitting for this to be an imperfect therapeutic process, and that my accepting that was going to be instrumental in his progress.

Despite how imperfect it was, he did make progress. Candor, which had been ego dystonic, was becoming ego syntonic. His coping strategy was changing, and we both came to enjoy his increasing freedom to be himself in the sessions.

Treatment Process: The Agents of Change

My goal in treatment with most compulsives is to enlist their natural impulse to become a “better” person and put it in service of their psychological growth. With Bart I never used the word compulsive, much less mention the diagnosis “OCPD.” But I did note his strong, natural drive to succeed and to be a good person.

Bart did seem to get this eventually: “It's kind of like I'm waking up and realizing that the game I was playing, putting points on the scoreboard, was meaningless, but this process of understanding myself and feeling better is more important. It feels good when I get it, when I master it.”

These realizations included questioning the narrative that he had to be like either of his parents. Near the end of his treatment he told me, “I want to take the best of my mother and father, and not be so black-and-white about it.”

Another aspect of his narrative that we needed to question was whether his family needed him only for money. Maybe they wanted him to be happy as well. Accepting this as a possibility required some vulnerability on his part. He couldn’t remain aloof if they actually cared about him. I believe that his work on opening to feelings in our sessions was instrumental in allowing him to feel closer to his family.

On occasion he wanted assignments for the week. I chose exercises to help him become more aware, in the moment, of how his old coping strategy affected him. For instance: “Try to notice when you stop yourself from feeling good. Count the times you do it. Just noticing it is great.” And, “Notice how many times perfectionism leads you to attack yourself.” Compulsives love to count. What he counted was changing.

We explored different parts of his personality. “What if I’m an asshole that just likes money? What if I just like being seen as generous but I’m really not?”

“Yes, part of you likes money, and part of you likes being seen as generous. Those are both okay. And there is more to you. There is also a part that genuinely likes to be generous whether anyone sees it or not.”

He wondered if it was okay to be ambitious. Somehow it didn’t feel right. The more we processed this, the clearer it became that it wasn’t so much money that was important to him, but achievement and mastery. There was a part of him that loved challenges. To say what he loved was a new expression and marked acceptance of a part of him that he had only vaguely recognized before.

Accepting his introversion was another challenge. He definitely liked his time alone but felt guilty about it, which of course meant that spending time with his wife and others felt like it was in the “should do” column, not the desire column. In the long run, he came to appreciate both being alone (without guilt) and spending time with his family, because it was no longer a “should.” As different parts of him came out of hiding, it became clearer what was important to him.

All these elements served to reduce the insecurity he felt, so that he didn’t need to prove himself…as much.

Termination

After 19 months Bart felt well enough to end treatment. We spent a few weeks processing the termination, especially what it was like for him to end it rather than me. I would have liked to see him longer, but that may have come out of my own perfectionist ideas about how long treatment should go on and what it should accomplish.

I would like to have seen him develop more comfort with the therapeutic process itself, but that too comes from someone whose intense interest in psychology developed when he was a teenager. Maybe not everyone needs to be comfortable with therapy, much less actually enjoy it. It was a very good sign that he decided to end treatment rather than feel he needed to stay to please me. I hope my acceptance was healing.

“I will never know how much, if any, of his progress was a well-performed recovery”. But I suspect that even if his first efforts to be authentic were to please me, they eventually became truly authentic. I suspect that he had experiences and insights that will help him change and be more fulfilled, even well after our work is finished.

Working with compulsives has forced me to examine my own biases, my own need to control, and my own rigidity. If nothing else, I learned that I can’t expect my patients to become any more flexible than I am myself. This includes challenging my own fixed ideas of how treatment should go with each new client.

Conclusion: Poison as Medicine

Jung said that individuation is a compulsive process, that we are compelled to become our true, authentic selves. When that process is blocked, neurotic compulsion ensues.

When we recognize the constructive potential of the obsessive-compulsive personality, we can help make it less “disordered.” When we recognize the energy that’s gotten off track, we can help direct that energy back toward its original, healthier path. The adamancy about doing the “right thing” that turned against the client and the people around them can be enlisted to help them find their way to a more satisfying way of living.

The alchemists were known for trying to transform lead into gold, which was really only a metaphor for transforming the poisonous, dark struggles of our lives into the incorruptible gold of character. But I think that this metaphor works best when we understand that the gold was there all along, obscured and waiting to be released.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Diedrich, A., & Voderholzer, U. (2015). Obsessive-compulsive personality disorder: a current review. Current Psychiatry Reports, 17(2), 2.

Haslam, N. (2003). The dimensional view of personality disorders: a review of the taxometric
evidence. Clin Psychol Rev, 23(1), 75-93.

Hertler, S. C. (2015). The evolutionary logic of the obsessive trait complex: Obsessive
compulsive personality disorder as a complementary behavioral syndrome. Psychological
Thought, 8(1), 17-34.

Koutoufa, I., & Furnham, A. (2014). Mental health literacy and obsessive–compulsive personality disorder. Psychiatry Research, 215(1), 223-228.

McIntosh, P., Paulsen, L. Mental health literacy of OCD and OCPD in a rural area. The Journal of Counseling Research and Practice, 4(1), 52-67. Available at https://egrove.olemiss.edu/jcrp/vol4/iss1/4.

McWilliams, N. (2014). Psychoanalytic Diagnosis. The Guildford Press.
Pinto, A. (2016). Treatment of obsessive-compulsive personality disorder. In E. A. Storch & A. B. Lewn (Eds.), Clinical handbook of obsessive-compulsive and related disorders (pp. 415-429). Springer International Publishing AG. 

Charles Mansueto on Obsessive Compulsive Disorder

Posted on by rezendevknowfully.com

OCD and Its Misconceptions

Victor Yalom: We can assume that our readers who are therapists and students of therapy or counseling or social work know something about obsessive compulsive disorder, but may not have a great deal of expertise. So what are a couple of things that therapists don’t know or may misunderstand about OCD?
Charles Mansueto: Well, the first misconception is that it’s amenable to a broad range of psychotherapeutic interventions. It’s not. It appears that that the treatment that’s clearly effective and has been well tested is cognitive behavior therapy. The second kind of treatment that is available is pharmacological treatment that typically impacts the serotonin system.

The first misconception is that it’s amenable to a broad range of psychotherapeutic interventions. It’s not.

Because it’s widely thought of as a brain-based or biological disorder having a biological substrate, one misconception is that it needs a biological solution, that a person must be treated with medications to correct whatever anomalous conditions exist when OCD is present. That’s not the case. The learning-based treatment, Cognitive Behavior Therapy (CBT), has been established and continues to be emphasized as the treatment of choice in the vast majority of cases.

VY: We hear that about so many conditions now that they are biologically based, and I think many therapists are skeptical. What’s the evidence for OCD being biologically based?
CM: The evidence comes from basic studies of brain scans. Some early research, for example, identified the activity in the brain that occurs when OCD is present as identifiably abnormal. I participated in a study with Judith Rapoport using Pet Scan imaging. We found that when the cortex, the thinking brain, perceives a danger of some sort, it transmits a signal down to deeper structures of the brain. In people with OCD, the caudate nucleus seems to not be able to regulate these worrying signals. But when OCD has been treated successfully, either by the serotonergic drugs or by cognitive behavior therapy, there’s a degree of normalization of brain function. There’s a lessening of that repetitive activity within the communicative structures in the brain.
VY: So with brain studies, there’s some clear differences between people with OCD and the “normal population,” and there’s a difference between pre-treatment and post-treatment OCD. Is that what you’re saying?
CM: Exactly.
VY: But I’m sure looking at the brain you could find brain differences in many groups of people. That doesn’t prove that it’s a neurologically-based. That’s correlation. So what other type of evidence is there?
CM: Well, there’s the family studies that show a greater-than-chance-alone incidence of OCD within families. So there’s a suggestion that there’s a genetic element to the transmission of OCD. There are other possibilities, of course—cultural transmission, social transmission—but there’s strong evidence for some genetic linkage.
VY: And then there’s some more intriguing evidence of OCD being related to Tourette’s syndrome, which I know you have done a lot of research on.
CM: Those of us who treat OCD frequently often come across the co-existence of OCD and tics and Tourette’s syndrome, most often in children. There is often great difficulty in distinguishing between complex tics in adolescents, for example, and compulsions. So the question comes up often: Is this is a tic? Or is it a compulsion? Now those have important treatment implications because we have different sets of tools for OCD versus Tourette’s. But there are a lot of close similarities and an intriguing connection between the two that hasn’t been well-clarified in the literature.]

Strep Throat and OCD

VY: I recall hearing in the past that there was some potential linkage between Tourette’s syndrome and strep throat. Is that true?
CM: Yeah. It’s called “PANDAS,” Pediatric Autoimmune Neurologic Disorder Associated with Strep. Cute name but not a very cute disorder. Sue Swedo and others have pointed out that there seems to be a link between rapid onset in childhood strep infections and, in some case, the emergence of OCD-like symptoms, tic symptoms, and an array of other presumed neurological symptoms, like hyperactivity.

There seems to be a link between rapid onset in childhood strep infections and, in some case, the emergence of OCD-like symptoms, tic symptoms, and an array of other presumed neurological symptoms, like hyperactivity.

More recently, there’s been speculation that other diseases, such as Lyme Disease, might also be able to initiate or exacerbate symptoms of OCD and some of these other related kinds of problems. Now that it’s been identified as such, we’re seeing more and more children who are presumed to have a biological-based onset—or infection-based onset—of OCD and these related problems.

VY: So there are multiple ways that this might manifest, in terms of symptomatology—a lot of complexities there.
CM: Well it adds the possibility of environmental causes. So it’s not just that a traumatic incident or a biological vulnerability are the only causes, but relatively common infections may also be implicated in the etiology of OCD.
VY: Has the traditional psychoanalytic/psychodynamic explanation for it been totally discredited?
CM: Well, it’s certainly very interesting and compelling, but it’s very hard to prove in research, as you might guess. But more importantly, treatments based upon psychoanalytic and psychodynamic presumptions do not seem to have a significant impact on OCD, at least in the cases that have been researched.

OCD and Obsessive Compulsive Personality Disorder

VY: Is there any correlation at all between what we think of as obsessive compulsive personality disorder and OCD? Or are those two really quite distinct things?
CM: Well, they are distinct, but again they’re curiously related. We do distinguish the disorders, putting them in two different parts of the DSM and they’re differentiated relatively easily from diagnostic criteria. However, my own view is that we’re talking often about how ego-dystonic versus syntonic it is. In other words, how much does a person who is extremely orderly and very concerned about germs and cleanliness— how much do they value that? Do they see that as part of themselves, the way they are? Their own characteristics as opposed to something that happened to them that they would like to get rid of?

Treatments based upon psychoanalytic and psychodynamic presumptions do not seem to have a significant impact on OCD.

With OC personality disorder, one distinction that’s made is that the behavior is ego-syntonic. The person doesn’t necessarily want to give up this part of themselves because it’s well-integrated into their overall functioning, their value system, their dispositions to action and their history. With OCD it’s more dystonic. It’s something that happens to me and I want to get it out of me at all costs.

But we do see a continuum here. We see individuals who are more or less committed to maintaining their particular approach to life, their perfectionistic tendencies, their extreme cleanliness, their methodical orderliness, to the point where they are doing more organizing than they are working; it becomes very dysfunctional. So I’m not convinced that we are talking about two totally different populations. But that’s the way we think diagnostically.

VY: Let’s talk about the course of the disorder. Let’s say someone has classic OCD—hand washing, door checking, those types of behaviors. When does this typically start and if left untreated, does it tend to go throughout the course of their life?
CM: Well, we don’t have perfect information on this because we only see people who are in trouble, when things haven’t resolved. So there may be people out there who experience significant OCD that then resolves, but we don’t see those individuals very often. But typically, OCD occurs in children around age eight, nine, ten or there is another onset cluster in late puberty/early adulthood. Whether they’re identical is up for some debate. There do seem to be differences in many of the childhood cases we see. Some of the work I’ve done with what I’ve come to call “Tourettic OCD” tends to appear more typically in childhood.

Whether a person gets it early or later, it seems to be chronic when left untreated.

But whether a person gets it early or later, it seems to be chronic when left untreated. It does wax and wane though. There probably are many individuals who are able to adapt and continue to live reasonably productive and happy lives. But for many individuals it becomes a true disorder, in the sense that it substantially decreases their ability to be happy and satisfied with the quality of their lives.

VY: Right, you said that obsessive organizing behaviors interfere with work, but I imagine it can also interfere with relationships.
CM: Very much so. We work with a lot of families, and a whole family’s life can revolve around the OCD of one individual within that family.

Treating the Family

VY: Does an example come to mind?
CM: Let’s say an older adolescent or a young adult continues to live with the family, with the parents, and the parents realize that the person is impaired, and very dependent on them. Well, as parents often do, they try to keep the person as comfortable as possible, as comforted as possible, and that means they begin to adapt their life to the needs of that individual. Those needs can often be excessive and very bizarre. It may involve cleaning and separating dirty things from clean things. It may involve strange eating patterns. But the family becomes more and more inclined to revolve and have their home life dominated by those requirements. In that case, we have to often treat the entire family.Now that’s more typical of children and adolescents, obviously, but we see people who are up there in age and they worry that their child cannot exist without them and their time is limited. Those individuals often reach out in desperation even though their loved one is unwilling to get treatment and just simply wants everyone to continue to cater to their unique and idiosyncratic needs.

VY: It becomes a kind of codependent situation where their attempts to comply or adapt to the OCD sufferer probably reinforces it.
CM: It’s a big problem. At the OC conferences, we often have rooms full of parents who are there because their children—usually adolescents or young adults— wouldn’t come. They’re trying to figure out how to get their children to agree to participate in treatment.
VY: Let’s delve into treatment. You mentioned that cognitive behavioral therapy is the treatment of choice?
CM: Yes. The expert consensus guidelines were developed in the late 90’s, 1990’s, and haven’t been modified since because, except for the addition of a few medications into the treatment approach, the guidelines are still very solid. About 70 or so treatment experts from around the world were asked to put together the guidelines for those who are not experts at treatment.I think just under two-thirds were medical people, MD’s, and across the board, CBT was recommended for individuals with OCD, sometimes in combination with medication for more severe cases. But medication alone was seen to be a second best treatment, except in the case of more severe adults. Essentially CBT is the treatment of choice, and we do biofeedback, relaxation training, assertiveness training, all under the umbrella of CBT.

The Experts Agree: The Solution is CBT

VY: We’re a field that doesn’t always easily come to a consensus about what to do when you’re sitting with another human being in the room to help them with their malaise, but it sounds like at least for the treatment of OCD, there is a higher consensus than we typically find.Let’s get into the specifics of CBT treatment. Let’s take a prototypal case—a hand washer or a checker who’s checking the locks or checking to make sure that the stoves are turned off. Let’s say this is someone who is coming voluntarily to your office and wants to get some help. How do you start out?

CM: Education first. There are things to know about OCD.

It can feel very mysterious and just because someone has it doesn’t mean they understand it.

It can feel very mysterious and just because someone has it doesn’t mean they understand it. So the first step is to help explain that there are understandable relationships between symptoms and elements within OCD. It’s important to explain this because it suggests that there are proper lines for treatment.

VY: I assume you have to do some kind of assessment on what type of OCD they have, what’s the severity, what they’ve tried so far.
CM: Most people have received some treatment when they first come to our treatment center, but not proper treatment—not CBT and often not even the appropriate medications.The letters themselves tell something about the problem. First there are the obsessions—whether it’s about germs and contamination, or locks and safety from marauders, or fear of displeasing God—whatever the nature of the obsession, there’s typically a belief in a threat that must be avoided at all cost. These obsessions have a negative emotional impact; there’s often a great deal of anxiety and shame that accompanies them.Next we have compulsions. There are two ways of being compulsive. One way of being compulsive is to avoid any circumstance that arouses those ideas and fears associated with the obsession. So I might try to avoid thoughts that are negative towards other people if I fear that God is displeased by that, or lascivious thoughts. Or I might try to avoid touching doorknobs or coming in contact with people’s hands because I fear that I may pick up some disease.

VY: So those are the avoidance type of compulsions.
CM: Yes, those are avoidance compulsions. The other type of compulsions are the rituals, which are used when certain things can’t be avoided. So pleading with God for forgiveness for having improper thoughts, praying over and over in certain ways to ensure that God realizes that I wish to be forgiven and am unhappy with my behavior.Or the washing that’s done in order to get rid of the possibility that there are germs on me, and the obsessive scrubbing and showering and cleansing of clothes and so forth. Or the checking of locks over and over because maybe I missed the lock or I accidentally unlocked it instead of locking it. Or that just looking at it isn’t enough. I have to check it physically or ask others to reassure me that the lock is, in fact, well secured.

VY: Listening to this, I’m imagining psychodynamic-oriented people finding these behaviors rife with potential meaning, but you don’t go there in your approach, right? You don’t put too much effort into figuring out what the meaning of these things are?
CM: Well, there are situations where some traumatic or highly stressful experiences of the individual might have preceded certain kinds of problems. But that’s not critical. The origins of the problem don’t seem at all essential to a successful treatment of the problem. Nor does insight necessarily produce the kind of improvements that one would hope for. So we think of insight into the origin of the problem, or understanding the meaning of it and so forth, as somewhat autonomous from the alleviation of the problem itself.

Avoidance and Its Discontents

VY: So getting back to treatment—once you’ve done some sort of assessment and have a sense of what the obsessions or the compulsions are and how severely they’re impacting that person’s life, then what do you do?
CM: Next you point out the way these behaviors often worsen the condition. Let’s take a common example: A child wants to avoid sleeping in the dark, but the parents insist that they stay in the dark, and maybe give them a little nightlight or open the door a crack. If they scream loud enough, will their parents leave the light on? No. Parents will say, “No, we’re going to turn off the light. You know you have to get back to sleep.” Avoidance is a way of maintaining fears.
VY: So if they cave in to the child’s demands and leave the light on, that’s going to reinforce the child’s fear.
CM: Right. It’s like not swimming in deep water isn’t going to help you get confident in your swimming ability in deep water. Not taking the training wheels off the bike isn’t going to make you a confident two-wheel bike rider. What we need is exposure to the experiences that cause us fear so that we can actually gain confidence and overcome our fear.

The origins of the problem don’t seem at all essential to a successful treatment of the problem. Nor does insight necessarily produce the kind of improvements that one would hope for.

Similarly with OCD, what we do is provide methodical and manageable levels of exposure to the feared elements, with the assumption—and borne out by our experiences—that the person will eventually become less fearful; and when the fear is lessened or extinguished, they have no longer have to perform rituals or compulsively avoid the original cause of their fear.

VY: You’re talking about exposure and response prevention.
CM: Mental exposure to things that cause us unwarranted fear, and then response prevention: encouraging the person to forego any abrupt reductions or eliminations of their fear, because the nervous system needs time to adapt. With repeated exposures, and saying, “Yes I know you’re anxious, but don’t wash your hands. Let’s let your nervous system get used to the fact that you have a great deal of nervousness and fear about this”—over time, what we typically see is a person becoming more comfortable with higher levels of fear-invoking distress.
VY: So how do you actually do that? These people are very invested in their symptoms so it can’t be easy. What are the steps? What do you do in the first session, the second session?
CM:

We have to come across as knowledgeable experts in order to instill confidence in them to allow us to lead them into the belly of the beast.

In orthodox, standard treatment, there’s the cognitive therapy component, where there’s a great deal of education about the way these things work—why their efforts to remain comfortable are thwarting their wishes to overcome their OCD. This educational component is key and we have to come across as knowledgeable experts in order to instill confidence in them to allow us to lead them into the belly of the beast. We have to do it in a way that allows them to experience some of these corrective measures, so that they can say, “Whoa. I’m much more comfortable doing this than I ever imagined I could be.” That’s the first step out of the pit.

VY: So you start by explaining how the treatment’s going to work and establishing yourself as an expert so that they’ll do what you tell them to do.
CM: And the proof’s in the pudding.
VY: So with the hand washer, will you give them some homework in the first week?
CM: Yes.

“Do You Know Somebody Who Got AIDS from Touching a Doorknob?”

VY: Do you tell them to go cold turkey?
CM: Not usually, because these fears are heavily entrenched and have been reinforced over a lifetime. So there has to be a great deal of preparation, cognitive therapy, correcting of misconceptions and identification of distorted thinking to help prepare the person for more experiencing and tolerating of their discomfort.
VY: So how do you do that? If these people have a very strong belief, bordering on delusional, that they’ll get AIDS from touching a door knob, for example, how do you get them to start touching door knobs? Clearly just presenting them with their distorted thinking isn’t going to be enough, right?
CM: Well, you start with simple observations like, “Other people seem to be touching doorknob quite regularly. Are your friends who touch doorknobs dropping like flies from AIDS? Do you know somebody who got AIDS from touching the doorknob? Have you ever heard an expert who understands disease processes suggest that we should all avoid touching doorknobs because AIDS or some other deadly diseases can easily be transmitted?” You start point out flaws in the thinking process.
VY: So having a logical discourse can be effective?
CM: It helps. It establishes a foundation of looking at things differently. These people are not crazy; they’re very intellectually competent, in fact, so they’ll begin to take notice of the many inconsistencies in the way they address these things. They might have a magical way of ensuring that they don’t get a disease—for example rubbing their hands on their pants six times.

We might ask, “What scientific principle suggests that rubbing it six times makes you safe, while rubbing it seven times or five times doesn’t?”

So we might ask, “What scientific principle suggests that rubbing it six times makes you safe, while rubbing it seven times or five times doesn’t?” And they’ll go, “Wow. Yeah, now that you mention it, it sounds kind of silly.” We begin to undermine their notion that this makes sense.

Nobody wants to live life like this. They’re just so afraid of giving it up. So they really want to believe you when you say that they can get over it, because life can be such hell for them otherwise.

VY: So cognitive preparation can be helpful. What do you give them as homework the first week?
CM: Well, homework might be to monitor. The chunks of useful information for setting up treatment are the many things they avoid. Why? Because avoidance exposure is the opposite of avoidance. Anything they avoid doing is potential fodder for the exposure experiences. So they don’t touch doorknobs; they won’t eat off a fork that hasn’t been rubbed with a disinfectant wipe; they won’t shake hands with people; they won’t use public restrooms or touch any surfaces in a public restroom. All of the things they avoid doing become useful information to develop the exposure experiences. And on the other side of the coin, all of their compulsive behaviors—their washing, their separating clean things from dirty things, their asking for reassurance from others—all of those become the elements for response prevention. Those are the easy escapes, and we can’t have that during the course of the treatment, in order for it to be successful. So in the early stages of treatment, our goal is to get a wide array of potential exposure treatments, those things that they tend to avoid that ordinary folks don’t.
VY: So in the early stages of treatment, you first want them to be more aware of what they’re doing. And then you’re giving them some alternatives?
CM: You’re gathering information to become a collaborator in treatment. You’re saying, “You’re going to hate exposure. You’re probably a little nervous about it. But I’m going to help you understand why avoidance has been so detrimental to your life. You’ve worked so hard, but you’re more afraid than you’ve ever been about these things.”Originally they see the compulsions as the solution. “I’m going to avoid touching things that make me feel dirty. I’m going to do things that make me feel clean.” But soon they’re doing those things for hours and they feel more scared than ever.

VY: Okay. So the first week or two, what do you specifically give them to do as homework? Or tell them to do?
CM: There’s no one formula for how you start, how fast you move, and so forth. In fact, individually gearing it to the person, to their readiness, to the level of preparation they need and how much help they need with the exposures—these are all very important elements to ascertain before moving ahead with the treatment. And this is where the expertise of the practitioner comes in.We might do a more traditional once-a-week treatment, or an accelerated treatment where people come more than once a week. There may be in vivo components in or outside the office where they’re getting exposure to the stressor. We can have intensive treatment, where over a shorter period of time, let’s say a month, people are getting very intensive daily hours of treatment.

But the general thrust of early treatment is to gather the correct information to build a road map for the treatment. And that involves the patterns of avoidance, the patterns of rituals that are used, and so forth. Then we develop a hierarchy, which is the essential part of the roadmap. Which things produce very little discomfort, which things seem outrageously anxiety producing, etc. Then we bring them through the different stages. So as they learn at each stage that they won’t meet their demise, we lead them through increasingly more difficult exposures.

Hierarchy for a Hand Washer

VY: What would be a hierarchy for a hand washer?
CM: Early on I’d try to find something relatively easy to work with. So if a client feels safe in their bedroom but not safe touching the bedposts because her mom touches them when she changes the sheet, I’d ask her to rate her discomfort on a scale of 1 to 100. The name of the scale we use is “SUDS,” Subjective Units of Distress. So I’d ask how anxious the bedposts make her and she’d say, “just a little bit.”

Our job is to titrate the exposures so that they are manageable and doable, and to ensure that the person is gaining confidence that the powerful emotional response and the belief in the catastrophic consequences that they fear are both diminishing.

So I would ask, “Would you be willing to just come in contact with that bedpost, and see what the emotional experience is like? Is it going to be awful? Is it going to be reasonable? Can you forego the washing? If so, for how long?” We try to probe into how people actually react. Sometimes it worse than they think, and sometimes it’s easier than they think.

Our job is then to titrate the exposures so that they are manageable and doable, and to ensure that the person is gaining confidence that the powerful emotional response and the belief in the catastrophic consequences that they fear are both diminishing. That’s the only reason why a person would move forward and give up all their safety mechanisms and participate in treatment.

VY: Alright. So in the hierarchy, the bedpost might be relatively low. The refrigerator door might be higher and the faucet in a public restroom might be a lot higher than that.
CM: Right, and typically we start with some exposures in the office, where it’s a safer environment and they don’t have a history of a great deal of compulsivity. The therapist becomes kind of a guide and a confidante and a trusted companion on the journey.As we go, we learn more about how the nervous system reacts and what’s going on in the mind of the individual, and then we can apply cognitive therapy and wait for the habituation as the nervous system reaches it’s kind of asymptote, and then begins to decline. It’s a very interesting and powerful experience for individuals. “Wow. I don’t feel as nervous now. When I think about it, it kicks up a bit, but somehow it doesn’t bother me as much as it did before.”

We emphasize the techniques, but so much of it is the importance of the relationship—the confidence of the patient in their therapist and the therapist’s sure hand on the tiller.

So there’s a lot going on, as you can see. We emphasize the techniques, the exposure response information, but so much of it is the importance of the relationship—the confidence of the patient in their therapist and the therapist’s sure hand on the tiller.Just knowing that whatever comes up, we’re going to know how to deal with it. That’s why the experience and the special training helps. At some point along the way, we’ll touch on how a person might go about getting that additional training that enables them to be confident at whatever their previous kinds of approach to therapy might have been.

No Reassurance Allowed

VY: Let’s carry this through a little further. So in an ideal scenario, you graduate, move up the hierarchy. They may have a feared response but, if all goes well, they’ll find that if they wait a bit and, with repetition, and with reassurance and—
CM: Well, not reassurance so much. Reassurance is an escape mechanism. We might even say, “Who knows? You might get AIDS. I can’t promise you won’t. You know, things happen.” So we can’t reassure them too much in the process, or it can become a type of ritual in itself. We have to allow them to address the uncertainty of their situation.

Reassurance is one of those subtle kinds of variables in therapy for OCD that can easily be mishandled by a therapist who is unaware of the importance of facing uncertainty.

It’s a balancing act. In a certain way, preparing them cognitively is also reassuring them that we know what we’re doing, that they can overcome their problem. But we have to watch out for specific reassurance when their anxiety is up that is designed to reduce it. You see? It feels important to distinguish this because reassurance is one of those subtle kinds of variables in therapy for OCD that can easily be mishandled by a therapist who is unaware of the importance of facing uncertainty. We often reassure our patients in treatment, but with OCD, you have to be particularly careful or you’re just colluding in the compulsivity of that individual.

VY: Coinciding with the publication of this interview, we’re releasing two videos with Reid Wilson, whom you know, and he even takes it a little further than what you’re saying. His approach really emphasizes the lack of certainty—not only do they have to tolerate the uncertainty, but to welcome and invite it.
CM: Yeah. And that’s very important, dealing with uncertainty, because we don’t know everything about this world. Our patients often come to our office on the beltway. They know people die on the beltway. Are they certain that they’ll make it? That they’ll go home? That they’ll be alive when they get home? The answer is no, they’re not certain. I’m not certain. The reality of the world is that uncertainty is part of the picture.We don’t know what happens after we die. We don’t know if there’s a God that is so vindictive that one false move and we’re forever tortured in hell. We don’t know that for a fact. We have to help people live with realistic uncertainty. With kids, you have to be a little more careful. If a kid believes the number 3 is a bad number and if they eat three M&M’s their parents may die, you have to be a little careful about saying, “Your parents may die, we can’t know for sure.” How that’s handled is extremely important. There are certain people who are going to be much more ready to deal with that part early on, and others who have to be handled very carefully along the way.

But Reid and others of us who work in this way realize that reassurance is a way to help people feel safe, and we can’t do that. We have to expose them to the idea that it may not be safe, but that we have to live our life as if it were safe, the same way we do when we go on the highway, or we eat unknown food. The food may send our body into some convulsive shock, but we eat it because we are willing to accept some uncertainty.

VY: So, following the roadmap that you’ve laid out, they would progressively move towards behaviors that are higher on the hierarchy, and in a good case scenario, they would experience some anxiety, but over time it would diminish or eventually even go away entirely.
CM: In most cases, there are some remnants of OCD symptoms. However, it’s like a person who was once a drinker and now is abstaining—they have to be a little cautious, recognize the danger signs, know what to do. An alcoholic wouldn’t go hang out at a bar; somebody who used to be very overweight doesn’t go shopping when they’re hungry or keep Halloween candy around the house for weeks before Halloween. We teach people how to recognize OCD, how it works, and essentially how to become their own therapist.

We don’t have a lot of repeat customers with an OCD treatment. People go out there and, if properly treated, they should have skills that enable them to live a reasonable life.

We don’t have a lot of repeat customers with an OCD treatment. People go out there and, if properly treated, they should have skills that enable them to live a reasonable life. It is important to understand that there is a potential for people to totally overcome their OCD and live a life that’s free of those problems, but realistically speaking, we have to prepare people for the likelihood that they have to remain vigilant to a certain extent, and have to retain the skills necessary to remain functional and symptom-free as possible.

“You Actually Do That?”

VY: With all therapies, there are usually stumbles and hitches along the way—setbacks, relapses. What are some typical challenges therapists and clients face along the way of navigating that hierarchy?
CM: Well, sometimes people cut corners. They cheat a bit. They may succumb to their compulsion and end up washing and separating at some point during the week. So compliance is extremely important. And because we’re dealing with a very anxious group—and rightly so, they’ve lived a life that’s been drastically altered by their fears and beliefs—we have to prepare them for the importance of compliance with the therapy. So that’s one challenge: people who aren’t quite doing what they tell you they’re doing.

Therapy can be a bit odd. We ask people to do things that ordinary folks don’t do—you know, putting a cookie on a public restroom toilet and eating the cookie…

The other, as I mentioned earlier, is people’s families. Families can be a problem themselves. We have kids who we’re trying to wean from hand washings, and Grandma says, “You’re not coming to the table without washing your hands, are you? Go right over there and wash them and be sure and use soap.” Well, that’s a bit of a problem. That’s why it’s important to educate the family about what we’re up to and why we’re doing it. Because therapy can be a bit odd. We ask people to do things that ordinary folks don’t do—you know, putting a cookie on a public restroom toilet and eating the cookie. We don’t think it’s really going to kill us, but it’s a yucky, you know?

VY: You actually do that?
CM: Sure. Because we’re asking people to go far with this, so that when they leave treatment, it goes back to normal. If you just bring them up to almost normal, there’s a tendency to backslide. So we want to take them to some rather “notable experiences,” I’ll call them, “memorable experiences,” where they say, “Wow, I did that, and I survived. So I’m willing to live my life in a more ordinary way.”So we tell them along the way, “This is yucky. I don’t like doing this. I don’t like reaching into a dumpster and rubbing my face with garbage.” But part of the training is to understand that our own sensitivities mustn’t interfere with therapy. It’s important to get experience and training in this so that we really understand what we’re up against, what people are up against.

The stress of life can also undermine treatment. Whatever we’re trying to do—whether it’s exercise more or get along better with our co-workers—when we’re under stress, it’s easy to slip back into old behaviors. That’s why so much preparation goes into relapse prevention. The latter part of treatment is mostly about preparing people to be their own therapist, and creating a plan that they can follow through on for different expected moments of weakness or the recurrence of some feelings that were perhaps attenuated for a while but, for reasons unknown, come back with a vengeance.

VY: So what might be an example of a relapse prevention plan?
CM: Self-managed exposure and response prevention would be one example. Let’s say I have a fear of dust and dirt and I’ve been doing a lot better after treatment, but one day I notice dust on me and I start to worry. I think, “What would my therapist say? Well, he’d say, ‘Hey, it’s just dust. It’s probably not radioactive material!”
VY: It’s not anthrax.
CM: “So now what do I do? I go and intentionally take a little of that dust and perhaps put it on me, put it on my shirt, so that it makes me feel uncomfortable. It’s kind of foolish to do. No normal person would do that, but I understand I have to use the most powerful tools that anybody knows about to fight back against OCD. ERP—exposure response prevention.” So they do those kinds of things. Self-managed exposure response prevention. It’s very important.But if they’re having trouble, they may need to call up their therapist and say, “I need a booster session. I just took a step backward, I tried to handle it on my own, but I think I may need some help.” So we’ll plan a little systematic approach and a little mini-therapy session. Relapse prevention is preparation for the inevitable human failings, setbacks, weaknesses, and so forth.

VY: So even though it’s a fairly structured form of therapy and there is a lot of technique involved—a roadmap—there’s a lot of creativity involved as well.
CM: Absolutely. We learn from every patient. There are always new twists. The OCD is a product of the person’s own imagination and creativity, so everyone has their own twists and turns.

Training for Therapists

VY: From what I can gather, therapists who don’t have specific training in treating this and just kind of incorporate it into traditional talk therapy are unlikely to have effective results.
CM: Well, it depends on the case. Some cases are relatively simple and a highly motivated individual with a therapist who grasps things well enough not to make some of the common mistakes in treatment can do quite well. So it is possible to pick up a book about it—there are some good manuals out there that tell therapists how to do this as well as some good self-help books that therapists can use. It’s possible to be effective in some cases without extensive training.On the other hand, more difficult cases are challenging even to the most experienced therapists. There are going to be cases that are difficult to treat under any circumstances and that’s where more experience, more heads in on the treatment make a difference. Creativity and troubleshooting problems can be essential to moving smoothly through treatment. It rarely goes according to the cookbook, you know?

VY: If someone reading this interview wants to get more in-depth training, where would you suggest they go?
CM: An excellent place to get that is through the International Obsessive Compulsive Foundation’s Behavior Therapy Institute. It’s a wonderful three-day certificate program. It’s been developed over almost two decades, and provides excellent preparation for individuals who may never have had much experience, or any experience, with OCD. After the training there is follow-up guidance, supervision by phone—people can get really a huge jump in competence in treating OCD.It’s so important to develop more practitioners. As it is, there aren’t enough trained competent practitioners to deal with the large numbers of individuals with OCD. There are whole states where there are very few places to get competent treatment. Not only is it important from the standpoint of the sufferer, but for practitioners. This is an extremely rewarding area to work in.

We do get those Hollywood endings where people just shed their symptoms, hug the therapist, and walk out into a whole different kind of life.

We do get those Hollywood endings where people just shed their symptoms, hug the therapist, and walk out into a whole different kind of life. That isn’t so common with some of the problems we treat.

Just the fact that we’re there and we know what we’re doing ensures that we’re going to get lots of love from our patients, because they’ve often been through some harrowing times when they didn’t understand what was going on, when they got misguided advice from professionals; so when they finally feel that they’re getting competent treatment, there is very often a great deal of positive emotion generated by that alone.

And they pay their bills. The OCD persons are often achieving, smart, and conventional in many ways. So it’s very rewarding. Those of us who specialize in OCD treatment never get tired of it. I have almost 20 people in our center who love to treat OCD and get very excited about new cases that, while challenging, are teaching us new things every day.

VY: Do you treat other conditions as well?
CM: Well, once you treat OCD, you’re going to also be treating things under the broader OCD umbrella. There are many disorders that are now considered OC spectrum disorders—things like body dysmorphic disorder, where people perceive ugliness in themselves and are often very depressed and very distraught. Also hypochondriasis or health preoccupations—the person believes that every ache and pain is some deadly disease and bug their doctors to death, or do doctor shopping, looking for someone who will take them seriously.I already mentioned that we see a great deal of commonalities in Tourette’s and OCD. We also treat trichotillomania, hair pulling disorder, and excoriation disorder, skin picking and the picking of acne or the picking of skin around the body, fingers, toes, legs, scabs, mosquito bites. That just made it into the DSM-5, by the way.

VY: I understand there were some other changes in the DSM-V in terms of classifying some of these related disorders?
CM: Tic-related disorders are pulled into the mix. There’s now an identification for a subtype where tics and OCD appear within the same individual. We’ve conceptualized something called “Tourettic OCD” that’s very similar, but we don’t believe that its necessary for tics to be present for it to be Tourettic. It’s more that certain kinds of OCD are really discomfort-driven, rather than anxiety-driven, and therefore it’s similar in many ways to the experience of Tourette’s.Even Asperger’s syndrome, or what the DSM-V now calls Autism spectrum disorders— very often people are referred to us who say they have Asperger’s or they have pervasive developmental disabilities, but they also have OCD. Well, they may or may not. They may fit a sort of OCD configuration, but they may not be exactly OCD. They may have stereotypies, or they may have hyper-interests, where they just love everything about Pokemon or something. But it’s not OCD. These are more repetitively driven things. They’re not driven to do stuff because they feel very uncomfortable and frightened unless they do them. They do things because they just love to do those things.

VY: That’s an important distinction.
CM: It is, because a lot of things we call compulsive—some people love to shop or love to gamble or love to act out sexually—that doesn’t mean they’re obsessive compulsive. They’re exhibiting repetitive patterns of behavior, but the treatment’s quite different. If you treat OCD and identify it as treating OCD, you’ll eventually learn how to distinguish them from each other, and when it’s best to refer them out, in the case of something like internet addiction. People call up all the time saying, “My son is obsessed with the Internet. He plays videogames all the time. I understand you treat OCD.”“Well, yeah, we treat OCD, but that’s not OCD.” The importance of expertise is to be able to distinguish the subtle differences among some of the repetitive patterns of behavior that are often clumped and misidentified as OCD.

VY: Well I want to thank you for taking the time to share your wisdom and experience with us. You’ve gone into a lot of depth and, as is typically the case, though I’ve been in this field for quite a while, there’s always more to learn. I think our readers will have a similarly enriching experience and will be intrigued and interested in getting further training and expertise in treating OCD.
CM: I hope so. And I thank you for inviting me to participate here.

Psychiatry by the Dumpster: One Man’s Struggle with OCD

Posted on by rezendevknowfully.com

Editor's Note: The following article was adapted from Compulsive Acts: A Psychiatrist’s Tales of Ritual and Obsession, published by University of California Press, Berkeley (2008).

Three Feet

In a way, George was special from day one. I can still remember Dawn, my clinic clerk, paging me at 1:45 PM, three quarters of an hour after his first scheduled appointment, to warn me: “Oh, Dr A., you’re gonna love this one!”

“Please don’t tell me the patient just showed up,” I said. “How am I supposed to do a full intake in the remaining fifteen minutes?”

“I know,” Dawn answered, “but I couldn’t just let him go. I don’t know what to say, but he’s—how should I put it—he has his reasons for being late…. He’s different, even by our standards in this clinic, and even after nine years of doing this! I had to go out into the parking lot to check him in. That should give you an idea…”

“You went to the parking lot to check him in?” I asked. “Outside?”

“Yes, outside,” Dawn answered. “He can’t come in, he says. Our door isn’t wide enough for him.”

“Our door isn’t wide enough?” I asked, questioning whether I was the right doctor for this patient. “Did he mistake us for the gastric bypass clinic? How heavy is he?”

“Oh, he’s not heavy at all,” Dawn answered. “In fact, his wife tells me he hasn’t eaten in a few days. He’s just… I don’t know…Something about his nose… He won’t let anyone or anything close to it… He was so worried about his nose, he wouldn’t even get into the car this morning.”

“How did he make it to our clinic, then?” I asked. “I thought he lived in Belmont. That’s fifteen miles away.”

“He does,” Dawn said. “He walked here. His wife drove, but George walked.”

“He walked?” I asked again. “All the way from Belmont?”

“All the way from Belmont,” Dawn repeated. “That’s why I can’t simply send him back and ask him to reschedule. Anyway, he is checked in now and waiting for you over in the far corner of the parking lot, exactly three feet from the dumpster, where, I might add, his wife spotted your old, squeaky filing cabinet and asked me to help her pull it out and put it in her trunk. I’m no doctor, but she’s not right, either… What use could she possibly have for that cabinet? Anyway, what would you like me to do now?”

“Well, I guess my only choice is to come right down,” I said. “Meet me by the dumpster.”

“OK, just remember not to get too close!” Dawn warned. “You might frighten him. And, by the way, your two o’clock is here, too.”

“Great! Is my two o’clock at least waiting in the waiting room?” I asked.

“Yes, she is,” Dawn answered. “And I told her it was going to be a long wait…”

As I approached Dawn, who was standing in the distant corner of our parking lot, I noticed George in a vacant handicap spot by our recycling dumpster. In the adjacent spot, and having managed with Dawn’s help to squeeze my old filing cabinet into her trunk, stood his wife, now trying unsuccessfully to push the trunk door shut.

George was a lean twenty-something, with wide green eyes and a sunburned face and neck, probably from having walked a very long distance in the midday sun to come see me. His grooming and hygiene left something to be desired, and his dirty fingernails and caked hair indicated more that just the wear and tear of that day’s walkathon.

His wife started the conversation off. “Dr. A., thank you for coming out here to see us,” she said, still intent on shutting her trunk door, despite one of my old filing cabinet’s legs clearly sticking out. “I know this is not standard practice, but it’s very difficult to get him through doors anymore. I read up on obsessive compulsive disorder, so I know how to diagnose it. Heck, I may even have a touch of it myself… We’re here because we were told you were a specialist in OCD. It’s urgent, Doctor! Things have gotten completely out of control since it’s grown to three feet. Three whole feet!”

I was intrigued by the three feet, but realized that I had not yet introduced myself to George. However, before I could formally do that, George apologetically preempted my handshake.

“I don’t mean to be rude, Doctor,” he said, “but please don’t stick your hand out. I can’t do handshakes.”

“That’s OK, I understand,” I said. “I’m pleased to meet you anyway. Your wife just said that ‘it’s grown to three feet.’ What is it that has grown to three feet, George?”

“The radius around his nose,” his wife answered, her quivering voice betraying her anxiety. “He needs that much clear space around his nose at all times. In the good old days, it used to be that nothing could come within a foot of his nose, and we used to be able to joke about it. But when the radius grew to two feet, it was anything but funny, and we started needing to make lifestyle modifications: the having to sit alone in the back seat of the car, the trying to sleep standing up like a horse, not to mention—if I may go there in your parking lot—the challenging sex….”

I could see Dawn’s face clearly tense up at the idea of “going there.” George’s wife’s sexual comment was clearly in poor taste for Dawn and went against her deeply ingrained prohibitions about discussing private sexual matters even in clinical conversations—that is, if you can really call a parking lot discussion about symptoms a “clinical conversation.” Dawn’s anxiety, however, found immediate release when she abruptly broke off the filing cabinet’s leg that was protruding from the trunk, then threw it inside the car, which finally enabled her to close the trunk door shut.

The sound of the trunk door shutting, and the thought of securing the old cabinet for her home, caused George’s wife’s anxiety to subside as well, and a relieved smile made its way to her face.

“However,” she continued, more at ease, “even two feet weren’t enough. It had to grow to three feet, and, at three feet, it has been, well, impossible to accommodate!”

Steering the conversation back to the principal patient, I asked, “How long has this been a problem for you, George?”

“Oh ever since… I don’t know… It sort of crept up on me,” he answered.

“Ever since his brother died,” his wife continued.

“When did that happen?” I asked.

“Two years ago,” George answered. “He died in a skiing accident.”

“I’m very sorry to hear that,” I replied.

If sex had been a difficult subject to discuss in the parking lot, death would have been even more so, so I had to ask George, “I know this is hard for you, but can you try once more to come up to my office so we can continue this important conversation in private?”

“I can’t. I’m sorry,” George answered, cautiously shaking his head. “Doorways are difficult for me. Hallways are challenging. And elevators are out of the question.”

“Nothing personal, Doctor,” George’s wife continued. “His father was visiting from Europe where he lives last month. We hadn’t seen him in two years. Well, George wouldn’t even give him a hug! All he could do was wave hi from a safe distance when he arrived at our house and wave goodbye when we dropped him off at the airport…”

Seeing that the entire first meeting would probably have to be conducted outside, I wanted to make myself more comfortable. I approached his wife’s car to try to lean against the door, only slightly moving in George’s direction in the process. George responded briskly, first stretching his arms out, then turning on his feet in a 360-degree circle, his arms fully extended. The move resembled a disc rotating on its axis, and its purpose, I surmised, was to make sure that the required radius of safety was not violated by my sudden movement, and that I did not put his nose in any danger.

Sensing that I may have inadvertently increased George’s anxiety, I tried to give him a little break and addressed my next question to his wife instead.

“You said you might have a touch of OCD, too,” I said. “Tell me about it.”

“Well, it’s really just a touch,” she said. “Nothing like this! I don’t worry about injuring my nose, although I should! I broke it twice already, once in a car accident, and once in a diving injury. My OCD, if we may call it that, actually makes some sense… It’s about making sure that I don’t run out of important things. ‘What if I need it one day?’ I always ask myself when I consider, or George makes me consider, throwing something out. And this simple question is usually enough to make me want to save the item, whatever it is. You can understand, then, how I built up my collection of pots and pans and cooking magazines and the cabinets where I eventually hope to store them all. Did I mention cooking magazines? This is probably my biggest weakness!”

“Indeed,” George agreed, gently nodding his head in agreement. “She has so many cooking magazines all over the kitchen, she can’t make it to the stove to cook!” he added, smiling at the irony.

“That’s right,” his wife agreed. “I honestly don’t remember the last time I cooked a meal for this poor man.”

“But despite the mess in the kitchen,” she added, “we still eat well—or ate well—I should say, until his symptoms began. When he was at one foot, he already couldn’t use utensils, so I would buy him pizza which he would eat alone in his office. We lived on pizza for months because it didn’t require a fork and a knife to eat. I would ask him, ‘George, how come the pointy end of a pizza wedge is OK, but you can’t use a knife and fork?’ and he would say that something about metal approaching his nose was much scarier than the pointy end of the pizza wedge. Well, I thought it was kind of tragic, especially for someone who loved to eat and appreciated food so much. But oh how I miss those days now! You see, when the radius grew to two feet, he couldn’t even eat pizza, so he started insisting on soups and fluids, served in plastic bowls without a spoon. Later, when the radius grew to three feet, he started avoiding coming home altogether. He thought it was too much of a hazard, with all my stacks of cooking magazines and other stuff strewn all over the house. He didn’t want to trip and fall and hurt his nose, he said. So he now rents a studio nearby and eats, oh, I don’t know what he eats, or if he eats… Look at how thin he’s gotten!”

George did appear thin, but more than his low weight, it was his disheveled appearance that marked him as unhealthy, so I asked him, “What about basic activities of daily living besides eating? Toileting and hygiene, for instance?”

“This is really embarrassing, Doctor,” George answered, looking down and away from me.

“I can’t shower anymore. I feel the showerhead is about to attack me. We even had a plumber come in to replace it. He said he would have to install the showerhead in our neighbors’ kitchen next door if he had to adhere to my specifications of how far it should be from my head when I’m standing in the tub! I know it’s crazy, Doctor, but I really can’t help worrying about it.”

“Worrying about things that don’t make sense, and constantly checking to make sure one is safe, are common symptoms in OCD,” I said. “It doesn’t mean you’re crazy. It means you have OCD and that is only a small part of who you are. The good news is that for many patients OCD is very responsive to treatment, so I’m glad you made the decision to come here today.”

It is important during a first psychiatric meeting to try to get a fuller sense of the patient than his symptoms alone, so I tried to enquire about George’s hobbies and work experience next. Unfortunately, the conversation would always come back to OCD. “What do you enjoy doing in your free time?” I asked. “Tell me more about the part of you that doesn’t have OCD.”

“Well, I used to sing in church,” George answered, “but I’ve had to give that up, too. The idea of standing in front of a microphone is enough to make me mute with anxiety!”

“How about work, George?” I asked.

“I used to work in a large advertising firm,” he answered. “I had to give that up, too. My cubicle got too small for my nose…”

George smiled at the visual—an expanding nose in a shrinking cubicle—and I smiled, too, appreciating this young man’s stubborn sense of humor, still evident despite the obvious stress he was under.

But many pieces of George’s life and history were still unknown to me, and I could feel a hundred questions racing through my mind, competing for my attention and begging to be asked. By that point, though, I was very late for my two o’clock appointment, still patiently waiting for me, so I had to leave George and his wife in the parking lot after getting a promise that they would return the following day so we could continue our “first meeting.”

I did not leave them alone, though. I left them with Dawn, hoping that she would use her powers of conviction to get George inside the car.

“If I can get that old oversized filing cabinet into your wife’s trunk and manage to shut the door, I think I can get you into the car, too,” she said to George as I walked away. I then cringed at what she might have in mind for George’s trip back home as I overheard her ordering George’s wife to open the sunroof…

"Other than this preoccupation with my nose…"

For our second meeting the following day, George still walked from his apartment to my clinic. With much encouragement from his wife and Dawn, George was able to enter through the building’s doors and climb the stairs to the clinic area, after performing a checking regimen that took a whole hour to complete: With each step he took from the building’s main door to my office, George would make a 360-degree turn on his feet, his arms fully stretched out to clear the space around him. Dawn led his wife to the waiting room so I could meet with George privately.

Once inside my office, George used one hand to move a heavy wooden armchair from one corner of the room to the center, using the other hand as protective shield for his nose in case he moved the chair too close to his face. He then very cautiously sat in the chair. As he did that, I found myself rolling my chair back into the corner to give him additional security.

“Why me?” was his first question.

“I wish I had a satisfactory answer for you,” I said, “but, like so many other psychiatric and medical illnesses we see, we are much better at treating them than at knowing exactly why a particular person develops a particular symptom.”

“Did I somehow catch it from her?” he asked, referring to his wife, but appearing suspicious about the premise of his question as though he knew beforehand that the answer would be “no.” “But I don’t hoard,” he quickly added. “In fact, I’m the anti-hoarder.”

“You cannot ‘catch’ OCD this way, George,” I said. “You would, however, have a genetic vulnerability to developing OCD if you had a close blood relative with it. However, even when OCD does cluster in families, its symptoms can vary greatly among family members.”

“Well, I don’t have any biological relatives with it, as far as I know,” George quickly said.

“Speaking of ‘catching’ things,” I said, “do you spend a lot of time worrying about contamination or pollution? How about frequent checking that doesn’t involve your nose? Any excessive cleaning, counting, touching, arranging, or worrying about other body parts besides your nose, now or in the past?”

“Never,” George answered. “Other than this preoccupation with my nose, I’ve always been a pretty laid back, relaxed guy.”

“Do you worry that your nose may be weak or somehow deformed and in need of protection?” I asked. “Do you think it looks abnormal?”

“No, I think my nose looks just fine as it is now,” George replied. “I’m very happy with it. I just want to keep it that way!”

“Do you have any reason to worry that it might not stay that way?” I asked. “Are you prone to accidents, for example? Have you ever seriously injured your nose or any other body part before?”

“Not really,” George answered. “I’ve always been the cautious choirboy and high school debater kind of guy rather than the contact sports type.”

Seeing that it was not the memory of some old physical trauma that was making George worried today about hurting himself, I wondered about a trauma he may have witnessed involving someone else, or even an emotional trauma. Thinking back to our first meeting when his wife related the onset of George’s OCD symptoms to losing his brother in a skiing accident two years ago, I said, “Tell me about your brother, George. Were you close?”

“Yes, very,” George answered, his eyes looking down and away. “I was supposed to go with him on his skiing trip, but a choir event kept me back.”

“I’m sorry to hear about what happened to him,” I said. “Is it true that your OCD symptoms began shortly thereafter?”

“As I said, it sort of crept up on me,” he answered, “but I would say sometime around then is when I started frequently checking my nose in the mirror to make sure that it was OK.”

The striking coincidence between the onset of George’s OCD symptoms and the loss of his brother is rich in meaning and symbolism. It is relatively common for patients with OCD to experience their first symptoms, or to relapse after a symptom-free period, as a function of external stress. But, beyond that, were George’s specific symptoms somehow determined by the nature of the stress? Could the unexpected loss of a young, healthy brother to a fatal accident have made George overly vigilant about his own environment and in desperate need to try to control it to prevent a similar sudden tragedy from happening to him?

However, before I could expound further on this hypothesis with George, we heard a light knock on the door. George’s wife then gently walked in, careful not to swing the door fully open in a way that might disturb George, who was still sitting in a chair in the center of the room. She was carrying an oversized bag which she carefully deposited on the floor against the wall. She then stood practically stuck to the wall.

“I thought I had given you enough time alone and was burning to ask you some questions about my role in George’s treatment,” she said. “For example, I feel sometimes like I’m colluding with him and making things worse, as when I agreed to unhinge and remove the French doors between the dining room and the living room to make the passageway safer for his nose. Should I have just said ‘no’ and expected George to deal with the anxiety of navigating the doorway? Did I do more harm than good by giving in to his OCD?”

“I think you raise a very good question,” I said. “It’s a difficult balance that you’re being asked to strike. On the one hand, it’s your natural instinct to help your husband when he asks for it, but, on the other hand, you know that giving in to his OCD can perpetuate his symptoms and allow him not to address them. In my opinion, the best way to handle this is to try to accommodate the severe OCD fears which, if not allayed, would paralyze him. However, you should try to avoid giving in to those lesser fears that you think he can handle on his own. There’s a way to do this that teaches him how to work through his anxiety and be more independent.”

As I tried to explain to George’s wife her role in treating her husband’s OCD symptoms, I couldn’t help but think of a possible indirect role she may have played in causing them. From my previous conversations with George about his wife, and from what I witnessed in the parking lot when she rescued a useless filing cabinet from the dumpster and took it home, it was relatively clear that George’s wife suffered from a form of OCD, too, manifesting primarily in hoarding behavior. Could it be that her collections of useless objects and magazines that are cluttering the house were even more obstructive to George than the French doors in the example she gave? Would another way to understand George’s specific symptom and his need for space be that it’s an unconscious attack against his wife for the hoarding that had severely cluttered their lives? By being so debilitated by objects that stick out, and by eventually needing to leave the house because of it, was George signaling to his wife his strong objection to the state of the house and her inability to fully acknowledge the extent of her own illness and get treatment for it? “A Freudian psychiatrist might read in George’s symptoms—and expose to him in the course of therapy—the following unconscious message towards his wife: It’s time for you to give the house an overdue cleaning, and it’s time for you to admit that you have OCD yourself and to do something about it.”

It was, of course, a delicate dance. While I wanted to try to point out features of George’s wife’s behavior that might have promoted and contributed to her husband’s symptoms, I could not afford to forget that George, not his wife, was my patient. It wasn’t my role to diagnose or treat her, especially since all that she was willing to accept was that she had only a “touch” of OCD. Still, I would have liked to gently explain to her the possible interplay between her “touch” of OCD and her husband’s full-blown condition, but another knock on my door followed by Dawn making her entry interrupted me.

Dawn was very careful not to swing the door fully open. Once inside, she positioned herself right along the wall, close to George’s wife, adding to the drama of the “set.” As it now stood, the configuration of bodies and furniture in my office was as follows: George in his chair in the exact center of the room, me in mine tucked in the far corner opposite the door, George’s wife standing completely vertically against the wall, and Dawn adopting the same position on the other side of the door from her. Between the two women, and also stuck to the wall, was George’s wife’s oversized bag.

“I’m not being unreasonable because I haven’t eaten all day,” Dawn said, referring to her annual Lent fast which she had just begun, “but we have a problem on our hands, and we better address this now.” Then, looking alternately at George’s wife and at the bag on the floor, she added, “You cannot do that. I saw you. You cannot take the cooking magazines from our waiting room. What’s in the dumpster outside is fair game, but not what’s inside the building! We can help you if you need help, but you cannot be taking our magazines, especially since we work hard to keep our reading material up to date compared to other clinics!”

An uncomfortable silence descended on the room which George finally tried to break with an attempt at humor. “I guess you have kleptomania on top of hoarding, my dear,” he said, gently shaking his head and chuckling briefly.

But there was nothing humorous in any of this for his wife. Her face turned deep red and her eyes tried hard to avoid the other three sets of eyes in the room. Seeing how much embarrassment she had caused, Dawn quickly sought to assuage her guilt. “But I promise to save any old issues for you if you want!” she quickly added.

"I cannot even hug my wife"

George did not wish to approach his OCD as a novel with villains and victims. He didn’t see a very convincing connection between his brother’s untimely death or his wife’s hoarding problem on the one hand, and the onset of his OCD symptoms or the nature of these symptoms on the other. The most he would agree to was that the overall level of stress that his brother’s death and his wife’s condition had caused him somehow made his vulnerability to OCD finally express itself.

And I basically agreed. I felt that pursuing these impossible-to-prove associations too forcefully against George’s stated preference could, paradoxically, lead him to attribute meaning to symptoms that he saw as essentially meaningless and indefensible. Following a psychoanalytic therapy approach that imbued symptoms with a rational dimension through cause and effect linkages ran the risk of making them “meaningful” and, hence, perhaps worthy of holding on to.

Rather, the idea of OCD as a chemical imbalance that happens for reasons that we do not fully understand is what resonated with George, in part because it took the blame away: It was no longer a personal failing on his part, nor was it his brother’s or wife’s fault. He had researched the serotonin hypothesis for OCD and was much more in favor of a chemical solution to what he viewed as essentially a chemical problem.

“So what SSRI are you starting me on?” George asked at the beginning of our third meeting, before I had fully discussed pharmacological treatments with him.

“I’m very impressed,” I said. “It looks like you’ve done your homework. Do you know how these medications work?”

“Something about serotonin,” George answered.

“Indeed,” I said. “Selective serotonin reuptake inhibitors, or SSRIs, work by increasing levels of serotonin in the brain.”

“What’s the likelihood of them working?” he asked.

“The response rate is around 50 to 60 percent, and it seems similar across all SSRIs,” I said.

“So how do you decide which one to give, then?” he asked.

“Well, I decide in part based on any previous medication trials you may have had,” I answered. “It’s also important to consider what else you may be taking currently, because drugs can interact which each other. If you have family members with OCD, we should look at what medications they responded to, since there seems to be a genetic component to response like there’s a genetic component to having OCD.”

“Well, I’ve never been treated for OCD before,” George said. “I don’t take any other meds, and I have no blood relatives with OCD to help guide us. So, it’s a clean slate!”

“Well, this leaves us with side effect profiles to help us decide,” I said. “The most likely side effect to this class of medications in a healthy young man would probably be sexual.”

“I cannot even hug my wife, let alone think of having sex,” George answered, smiling slightly at the irony. “Sexual side effects are simply not an issue for me right now.”

“Well, let’s start Zoloft, then,” I said. “It’s relatively clean and well tolerated. As with all SSRIs, though, when you’re taking them for OCD, you have to wait up to ten weeks for a response. The starting dose is usually 50 mg daily, and our target will be 100 to 200 mgs, if we’re not limited by side effects.”

"I feel fresh for a change"

Along with being his prescribing doctor, I also wanted to serve as George’s therapist, and, in many ways, George would have been the ideal candidate for therapy. A responsible and inquisitive young man, he seemed to have the youth and mental flexibility needed to make change possible and the creativity and faith it takes to see how the talking process can alter brain chemistry enough to effect this change. In the cognitive behavioral model, I imagined myself assigning him homework and him reporting back to me on his progress every week. I imagined focusing first on the basic tasks needed to meet some vital functions, such as food and hygiene. For instance, I would start by helping increase his comfort level with using utensils to eat normally again, while working on his fear of the showerhead. We could then move toward getting him back to work, perhaps part time initially, and maybe in an expanded cubicle. I would also try to help him gradually feel comfortable being intimate with his wife again: Maybe have him move back into the house at first but sleep in a different room, then in the same room but on the floor, then in the same bed, then have him hold her hand, then hug her, then….—unfortunately, though, it was impossible to get George to come in for the regular sessions needed for successful therapy. The length of time it took him to work through his anxiety enough to be able to make it to his appointments caused him to miss several sessions and made for an almost impossible therapy relationship.

On the other hand, George was very committed to taking his medication. So, instead of face-to-face weekly clinic meetings, I made the decision to treat him with the medication alone at first, and I monitored his progress and any side effects through phone contact every other week.

By our second phone contact after starting Zoloft (his fifth week on the medication), George’s voice over the phone sounded somehow more resonant and more self-assured.

“You sound clearer today, George,” I commented. “Are you feeling better?”

“I am,” George said. Then, sounding almost euphoric, he added: “But there’s also a technical reason for why I sound better.”

“A ‘technical’ reason?” I asked. “What is it?”

“Well, I’m calling from home, which helps,” he answered, “and I’m actually able to use the handset today! When I spoke with you before, I had to be on the speaker phone. I couldn’t tolerate the handset so close to my nose.”

“This is great, George,” I said. “Did you have to push yourself to use the handset for our phone call today? How much of a struggle was it?”

“It really wasn’t a struggle at all,” George answered. “I just didn’t think about it. It somehow didn’t occur to me today that the handset would hurt my nose. I only realized after dialing your number that, oh my God, I’m actually holding the phone! My only explanation is that the Zoloft must be doing its thing already…”

“I think you’re right,” I said. “I think we’re seeing an early response. That’s wonderful news that…”

“And I have more wonderful news for you,” George interrupted. “I also had a real shower this morning for the first time in a long while. I feel fresh for a change.”

“I’m sure that helps, too,” I said. “How about another basic function, eating? Are you still afraid of utensils and solid foods and can only drink fluids?”

“I certainly can’t handle pizza yet,” George answered. “The wedge thing still bothers me, so do knives and forks, but the good news on that front is that I can tolerate spoons now! For some reason, I’m more comfortable with round forms approaching my nose than pointy edges. That’s how I could eat a hamburger yesterday… A fat juicy one that tasted like the best burger I ever had!”

“It’s so nice to see you come out of this, George,” I said. “We’re only at week five, so we can still expect more improvement over the next couple of weeks. As I told you, many patients don’t get better until week ten or so.”

“Let’s up the dose anyway, Doc!” George said.

“Well, you’re tolerating 50 mg pretty well, so let’s go up to 100 mg and stay there for a while,” I concurred. “Call me at the same time in two weeks, and we’ll reassess.”

But before I could let George go, I had to enquire about his wife’s hoarding… We had decided that her behavior was contributing to my patient’s symptoms by increasing the ambient stress in the household, so I felt justified enquiring into it.

“Before you go,” I said, “can I ask you how your wife is doing with her hoarding these days? You said you moved back in, so I want to be optimistic and think that the house feels more hospitable to you. I realize it’s not my place to treat her, but…”

“Funny you should ask!” George interrupted. “You know, her mother who’s a neat freak, her father who’s a perfectionist in his own right and I who worry about hurting my nose,all have, for years, been telling her to clean the house up, but to no avail. Until, that is, your Dawn caught her in the act of stocking up! Well, I’m glad to report that your clerk’s intervention is working where nothing else ever has! Maybe out of embarrassment over what happened, my wife has, for the first time, decided to confront her problem. She has finally agreed to hire a professional declutterer that her mom recommended: a very methodical woman with a stern old nun quality to her who will not take no for an answer when my wife refuses to let her throw something—exactly what my wife needs! Well, ‘Mother Superior’ as we started calling her has already begun her journey into the heart of darkness that is our kitchen. The output so far, in case you’re wondering? Fifteen boxes of cooking magazines, yellowed with age, not extra virgin olive oil stains!”

Pizza: The Final Frontier

Exactly two weeks after our last phone contact, at the time of the scheduled call, instead of my phone ringing, I heard an assertive knock on my door. It was George, only much cleaner than at our last face-to-face meeting some two months before. His wife stood right next to him, her svelte frame curving slightly in George’s direction under pressure from his arm which he had wrapped tightly around her waist. Sight of the intimate-looking couple clearly indicated to me that the three-, two- or even one-foot rule was no longer in effect. And that George was probably not having sexual side effects!

“What a nice surprise!” I said, addressing George. “You look great.”

“Doesn’t he now?” his wife answered. “I have my husband back. He even drove us here!”

“And we have a gift for you,” George said, handing me a wedge-shaped present wrapped in aluminum foil and smelling of pepperoni.

“You brought me pizza?!” I asked, surprised and moved by this gesture.

“Yes,” George answered. “I bet no patient has ever given you pizza before!”

“No, no patient ever has,” I concurred. “This is a first, indeed. Thank you.”

“Well, pizza has been a recurring theme in our conversations,” George said, “and, in a way, it’s the best measure of how both silly and disabling my OCD was. All this makes it a fitting final thank you gift for you.”

“Well, I’m very touched, George,” I said. “Thank you again.”

“Wait!” his wife interjected, “It gets even better…”

“How much better can it get?” I asked, wondering what other pleasant surprises the couple had in store for me.

“It’s home-made!” George said, elated at the concept of a home-cooked meal.

“You’re able to use your stove again?!” I almost gasped as I addressed George’s wife.

“I can, indeed!” she said, “and we have our declutterer, or ‘Mother Superior,’ to thank for it! I just have to make sure I maintain now. ‘For each item that makes it into the sanctum of your home, an equal or larger item has to exit,’ she ceremoniously warned me at our last meeting.”

“In my experience, this is probably the best advice for hoarders and more likely to help than any medication or even therapy intervention,” I said. “Your approach of having someone do the throwing for you while you deal with the anxiety that this generates, and while you work on maintaining the result, is probably the way to go.” Then, turning toward George, I said, “What you have to maintain, and probably for a while, is your medication…”

“Oh, don’t worry, Doc,” George said. “I don’t plan to stop it anytime soon.” Later, watching George walk away from my office, his arm wrapped around his wife’s waist, all I could think of was how satisfying my cold pizza was going to be. With anticipation, I reached for the carefully wrapped wedge, slowly undoing the aluminum foil as I comfortably sat myself in the oversized patient chair in my office, turning it around so I could face the window. I raised my feet, resting them on the window sill, and prepared to take my fist bite. But as I was about to do so, an interesting scene unfolding in the parking lot outside my window caught my eye. I saw Dawn, all in black in observance of Good Friday, trying to catch up with George’s wife, carrying what looked like a high stack of magazines she had saved for her. I then saw George’s wife give her a big hug but decline the apparent gift, as suggested by Dawn energetically tossing the entire stack into the dumpster. The three then conversed briefly before George opened his car trunk, and all joined forces to pull a familiar-looking filing cabinet out of the trunk and throw it into the dumpster.

Pizza never tasted so good…

 

Reid Wilson on Strategic Treatment of Anxiety Disorders

Posted on by rezendevknowfully.com

What is Anxiety?

Victor Yalom: So, Reid—good to be here with you. I guess a good place to start would be to define what anxiety is and how you distinguish between normal, healthy anxiety and irrational or counterproductive anxiety?
Reid Wilson: Well, that’s a broad question. We’re programmed to be anxious when we feel threatened—whether it’s an immediate threat or a distal threat—so anxiety disorders break down, in some ways, like that. Someone with panic disorder is threatened by an immediate danger; someone with generalized anxiety disorder tends to worry about things coming far in the future. We define people who have anxiety disorders, loosely, as those who have irrational fears of those kinds of threats.But the body responds impeccably to false messages. That’s part of the trouble of trying to help people get better—so much of the anxiety disorder symptoms have to do with naturally occurring responses to a perceived threat. So in many ways, as we do the treatment, we work against nature for a while until we can bring someone into balance.

VY: Before we get into treatment, let me try and understand that a little better. Anxiety is a natural mechanism to protect us against threats, but when it becomes counterproductive, or when our sensation of anxiety doesn’t match what’s going on in our environment, it becomes a disorder.
RW: Right.
VY: And the range of anxiety disorders is quite diverse, right? You have general anxiety disorder, panic attacks, specific phobias, OCD, PTSD. Is there a commonality among those? Is it useful to think of those together, or are there things that are quite discrete?
RW: I think that the most difficult one to sort out is post-traumatic stress disorder and there’s a tremendous number of researchers who are trying to figure out what the common denominators are within post-traumatic stress disorder. With the other disorders, there is a great deal of commonality. People with anxiety disorders have an intolerance of uncertainty and distress, and much of what we need to address in treatment is about resistance—about all the fighting and pushing away of symptoms that people with anxiety disorders use to stay out of discomfort. It’s not so much that someone’s having uncomfortable symptoms, it’s their response to their symptoms. Their tendency is to go, “This is terrible. I can’t handle this. I need to escape,” and we need to change that response.What varies is the contribution of genetics. Obsessive-compulsive disorder is almost completely genetic, whereas someone with a specific phobia of animals can have little or no genetic influences and be much more influenced by traumatic experiences or environmental factors.

In terms of how people respond, there’s a lot of commonality as well. That’s why part of what I’ve been trying to work on over the years is how to peel away all these innovations and exercises and structures that we use for people with anxiety disorders down to the lowest common denominator.

VY: I’ve seen you work with clients, and this idea about changing their response to their symptoms seems to be a core of your approach, but it’s kind of counterintuitive to clients as well the therapist. Can you say a little bit more about that?
RW: Sure, but it’s not like I have invented a system that hasn’t been around for a while. If we look at what’s been going on with mindfulness approaches to treatment, some of the work that’s been done in Buddhism for a couple of thousand years has to do with stepping back and observing the present moment, not reacting to it personally, and not taking the events to heart, as most people do. Part of what I have been trying explore is how you get people from point A to point B as efficiently as possible.

From Resistance to Detachment

VY: And what’s point A? What’s point B?
RW: Point A is what we’ve been speaking of, which is the resistance, the fighting, the trying to get away—“It’s bad or wrong that I’m experiencing this.” Point B is detachment. When people resist their experience of anxiety or panic, there is a significant amount of psychic energy invested in that resisting. When working with people, I try to respect the degree of energy that’s going into the fight.To expect our clients to move from the intense energy of resistance all the way to detachment is too grand an expectation. That’s why we have a lot of trouble keeping people in treatment, or even having people begin the treatment to start with. When you’re shopping around for help with your anxiety, what you hear is, “You’re going to have to do exposure over a number of weeks or maybe months. You’re going to have to go toward these terribly uncomfortable feelings and sit with them for a length of time, and then you will begin to notice a change.” But people who suffer from anxiety disorders are concerned with the immediate moment. Everything gets very tight for them. Their concern is, “but what do I do right now?” That’s what I want to present to people.

VY: Just so I understand, when you talk about resistance and all the energy that goes into resisting, how would this work with panic disorders? Is it that lot of time and discomfort is about anticipating and fearing the panic attack rather than the panic attack itself?
RW: Certainly. A panic attack, which lasts for 30 seconds—actually that is a relatively long panic attack—is less than .1 percent of the day, but people will focus the entire day on trying to prevent themselves from experiencing another panic attack. Somebody with obsessive-compulsive disorder may only wash their hands for 25 minutes a day, or check the doors and locks and windows for a half hour a day, but when you ask them how long they spend obsessing, they might say, “eight hours.” It’s very consuming psychically. All that bracing is the energy that needs to be redirected toward getting better.
VY: So how do you get from A to B?
RW: I attempt to honor and respect the energy of the resistance and help clients use that energy in a different way. The opposite of being frightened and bracing against a sensation or a pending dangerous experience is to let go. But letting go doesn’t represent a change in the emotional state. I believe we need to maintain the degree of emotion—so the opposite of terror is, to some degree, excitement or desire.In other words, we’re going to move toward that which we fear with a sense of zeal. It really gets crazy. It’s already paradoxical to move toward it and here we’re doubling down. It’s not, “Oh what I need to do is face my fear, therefore I’m going to step into that crowded elevator”; it’s, “I’m seeking out that state that I’ve been afraid of.”

Exposure Plus

VY: So that’s what you mean by “strategic therapy” or “paradoxical therapy”—encouraging people to go towards their fears with a kind of relish?
RW:

Strategic therapy is messing with patterns. So we’re going to find the pattern, and then mess with it.

Strategic therapy is messing with patterns. So we’re going to find the pattern, and then mess with it. Telling people to go toward what they fear is exposure, but we’re trying to do exposure plus. Go toward it and change my emotional state to, “I want this feeling. I want this experience.” But we need to be clear about what we are asking people to seek out. People with anxiety disorders have an intolerance of uncertainty and distress, so what they need to seek out is not that crowded elevator, not that battery they perceive is contaminated, but the generic sense of uncertainty and distress.

That’s a really the hard sell for people because it requires them to separate from the content of their worries and invite in more generic uncertainty and distress. And then the frame becomes, “I want to get better. I want to be with my family again. I want to be able to take the job on the 23rd floor. I want to fly to my cousin’s wedding in three months.”

Habituation is a fundamental element of exposure therapy and we know from the research that it takes three variables to get fully habituated and get better: frequency, intensity and duration. So if they want to get better they need to have enough distress, frequently enough and for long enough to make this practice count.

But I want to teach them the most generic way to do this as possible, because what we know is that anxiety disorders run the life cycle. Somebody can finish treatment with us and be doing great and be down to “normal” in terms of anxiety, and then three years later have a whole other brush with either the same disorder or another anxiety disorder. So we want to train people in a protocol that they can brush off again and start using if and when they encounter the disorder again.

The Art of Persuasion

VY: How do you propose this to your clients in the first place, and how do you get them to that state of wanting to go towards their fear?
RW: Persuasively. That’s my job—to find any and every mechanism to help change their mind. So I’m going to work at the level of frame of reference and I’ll use examples of other patients. I’ll use metaphors, I’ll give analogies, I’ll use logic, whatever I can use. I told a woman the other day, “If your son were in fifth grade and had to play the guitar every night, you could imagine him going, ‘Darn, I have to practice now.’ But if he sat down with his high-school cousin who plays in a rock band, and saw how cool it was, this fifth grader would begin to want to practice guitar every night. You can imagine the difference between a fifth grader having to practice for an hour, and a fifth grader wanting to practice for an hour.” That is the kind of shift I’m seeking for my clients and I’ll use these kinds of analogies to help them understand it on a deeper level. Every angle I can find to start loosening up their rigidity and resistance.
VY: We recently filmed you treating two clients for a new video series on Strategic Treatment of Anxiety Disorders that we’re releasing along with this interview, and one thing I noticed about you is you really take charge. You’re very directive. You tell the clients what to do. You tell them what may happen.It’s very different than a lot of therapists are trained. I think whether we’re trained from a more client-centered or psychodynamic point of view, that legacy of therapists being somewhat passive and letting the client lead the way has seeped into so much of our training as therapists. I’m wondering if you’ve observed that therapists have a hard time with taking charge in the way that you do.

RW: I would challenge what you’re saying because, yes, I’m dogmatic and I boss people around and I can be very dominant. On the other hand, I also try to come across one-down in certain situations.

Yes, I’m dogmatic and I boss people around, but I also try to come across one-down in certain situations.

“I’m not sure about what I’m saying right now, but what do you think?” I turn back to them to find out whether they’re starting to understand what I’m saying. I give them a protocol but say, “It’s an experiment. Let’s gather information about it.” There is a balance between coming on very strongly to somebody and, at the same time, accessing a sense of curiosity.

When I train therapists to do this, it’s somewhat intimidating to them and counter to how they have learned to do treatment. But we’re also talking about therapists who come in to get trained because the patients or clients that they see are pretty tough nuts to crack and they need some therapeutic leverage to help people move along. So I think they are also receptive to the ideas.

VY: One client that we see you working with in Exposure Therapy for Phobias, presents with a fear of flying, which, upon exploration with her, you narrow down to claustrophobia—a fear of enclosed spaces and suffocation, not being able to breathe. You do classic exposure therapy with her—which I had heard and read about but never seen in action—where you actually put a nose clip on her, put a pillowcase on her head and wrap that pillowcase with tape. Later you get her to go inside an enclosed box. That requires, first of all, that therapists get out of their cozy chairs and stand up and move around. That’s something that many therapists have no experience doing.
RW: Sure, it’s a big step but people are relatively motivated because we have a certain percentage of people with anxiety disorders that have very rigid belief systems. If you don’t find a way to start cracking that belief system open, it’s very frustrating for you as a therapist.

Chasing the Anxiety Boogeyman

VY: So give us a sense of how this works over time. I get the general principals, but how does it actually play out over sessions?
RW: Well, I work at the level of principles so I am not technique-focused, and that already makes me a little different than other CBT therapists. I don’t start with, “Here’s how you get better.” I start at the level of, “Here’s how I perceive what’s going on now for you. Help me understand. You know yourself—let’s see if we’ve got a match here.”

Psychoeducation is a big part what I do, particularly around the physiological and neurological aspects of these disorders. I talk about the neurology of fear and what happens with the amygdala when we are scaring ourselves.

Psychoeducation is a big part what I do, particularly around the physiological and neurological aspects of these disorders. I talk about the neurology of fear and what happens with the amygdala when we are scaring ourselves. It’s important for everyone to understand this aspect, which has to do with bringing the amygdala into the threatening situation and letting it just sit there and experience the situation and discover that it’s secreting too much epinephrine. We do that by quieting the prefrontal cortex. We need to stop scaring our amygdalas so that we can be present in the elevator, in the grocery store, with our heart rate accelerated, and discover that it doesn’t need to make me us excited.

A lot of the crazy kind of talking we engage in has to do with refocusing the attention of the prefrontal cortex so that it doesn’t keep continually saying, “Uh oh.” We’re trying to override that message with an executive voice that says, “I can handle this. Let’s go toward this.” So we need that in place.

And then we’re sending people out with experiments to do in which they notice those thoughts popping up or have that sensation in their body that’s been scaring them and then step back enough to go, “It’s happening—it’s okay this is happening,” and then transform it to, “I want this. Give me more.”

My orientation is a set of principles founded on the notion that content is irrelevant. That’s the first step that I need to get across to everyone. Then I personify the anxiety disorder to help them detach from the content of their worries. I’ll say something like, “The anxiety disorder hooks you by picking a topic that is personal to you. That’s how it creates doubt and resistance in you.”

So, for example, if you’re a single mother with three kids and have just lost your job and are not sure how you’re going to pay the rent in two months, that’s very stressful for you and it certainly is going to cause you to worry. But if you develop a sub-routine of worrying throughout the day about it, there’s no redeeming value in that process. So in your case I’ll say, “the anxiety disorder picks the fact that you’re going to have a hard time paying your rent and taking care of your kids. That’s a topic that’s threatening to you as a parent with young children.”

VY: But why do you personify? Why do you say, “it picks?” Do you actually believe that, or is that a tool that’s helpful?
RW: Do I actually believe that? What we’re trying to do is put into language something that’s unconscious, so I believe not so much that as—
VY: There’s no an anxiety boogeyman out there trying to get us, right?
RW: Well, maybe. What I believe is that to perceive it in that manner is therapeutic. It is a way to begin to get a sense of what’s going on. That’s what I want to do—help clients get ownership in comprehending the disorder. What is the nature of the disorder? Why is it running me? In many ways, I’m unconscious of the game that’s being played on me, so I want to bring that up to consciousness.
VY: Alright. So going back to the example of the single mother and her worrying throughout the day, what do you do with that?
RW: First off is to distinguish the content. If I don’t distinguish the content from the process, she’s going to think I’m crazy, because she should be worried. So first we isolate out worries that are signals: “I need to go find another job and I need to go to the government to see if they can help me for this period of time”—these are worries that she actually has a responsibility for and can take some action on, and now is the right time to take action. That would be the definition of a worry that is a signal, and we’re not working on those so much, though we certainly have to problem-solve.
VY: That’s what you would call normal or adaptive anxiety.
RW: Right, exactly. We’re separating that out. We do need to do problem-solving. If I can help you with that, then I’m going to work with you on that too. But on the other side is the worry that is just noise—repetitious, unproductive thinking that causes distress. That’s the content that is irrelevant and that’s what we want to isolate. So we’ve got the circumstances of your life, and then we’ve got how the anxiety disorder has come in and taken hold of that.Another example: If you’re afraid to fly, I’m going to try to teach you interventions to relax on the plane; but if you think the bolts are going to fall off the wings, there’s nothing I’m going to do to help you be comfortable. That would be inappropriate.

If instead we can change the story and get somebody who has a fear of flying to understand that the discomfort they’re feeling is inside them, is their responsibility—it’s not about the pilot or bad mechanics—then perfect. That’s what I want. People come in with a list of 15 things they don’t like about flying, but if they can say, “basically it comes down to feeling out of control,” we’re in business. That’s a theme of all anxiety disorders that we want them to understand.

The second piece is coming to accept their obsessive thoughts. Whether it’s, “when can I pay my bills?” or “was that battery contaminated?” their job is to accept them, to be fine with them. That can seem like a crazy intervention for people because we don’t go the route of reassurance around content. Instead we’re asking them to say: “It’s fine. That thought popped up because I have an anxiety disorder. That’s what we do. We generate thoughts that freak us out. And so instead of freaking out about it, when it shows up, I’m going to accept it.”

In order to get to the place of acceptance, we’re going to play some kooky games, like, “Give me your best shot” and “I’m not worried enough—make me more worried.”

The Anxiety Game

VY: You use the term “games” a lot. What do you mean by games?
RW: Perceiving the disorder as a mental game. Personifying the disorder. When I have an obsessive thought or an anticipatory worry or dread that I know is noise, I want to step back and notice it. That, in itself, is an intervention: “Oh, I’m worrying again. Oh, there’s that thought.” Now the next thing I am asking people to do, if they’re going to play the game vigorously, is to ask the disorder to increase those reactions that they’re having.So, for example, if I’m having a worry about not being able to pay the rent at the end of the month and that’s scaring the bejeezus out of me, I’m going to step back and notice it, acknowledge I’m feeling afraid about it, and request that the anxiety disorder increase my worry: “Please give me another fearful thought. That really scares me, but not quite enough.” So I’m always turning to the disorder and requesting it increase what it just gave me.

Viktor Frankl was the first person to write about paradoxical intention, and how he framed it was: Look for your predominant uncomfortable sensation and ask that sensation to increase.

VY: This is what was referred to as “paradoxical therapy.”
RW: “Paradoxical intention” was what Frankl wrote about in Logotherapy. And I did that for 20 years or so, but about 10 years ago I made a little switch—from asking my heart to beat faster to asking panic disorder to make my heart beat faster.That does an interesting thing which is, “I’m no longer responsible for increasing my heart rate. The panic disorder is responsible for it. I can now turn my attention back to my task of the moment.” Now, when you’re really anxious, you’re not going to get very far away from your fear; your obsession may show up again in eight seconds. But my position is to return to that request—”Please make my heart beat faster.”

VY: It sounds kind of ludicrous.
RW: It’s absurd.
VY: Right.
RW: And that’s what we’re looking for.
VY: And how do clients respond to that, typically?
RW: Well, as long as I have them long enough. If they heard me in a lecture hall, they might walk away shaking their head, but if I have enough time with them, they can see what it’s like. We go through it for a while and, if I can convey it to them well enough and convince them to try it out, in low-grade experiences where they’re not highly threatened, they can experience themselves getting better. Experience is the greatest teacher. That’s why I want to convince them to experiment with it to one degree or another.You really have three choices: Resist, permit or provoke. And I think much of the treatment of anxiety disorders over the last years has been to “permit” symptoms, to “allow” myself to be anxious. Allow things to sit there inside me. Allow the worries to show up. But that’s where people are going to finish the work; it’s not where I think people should begin the work—which is to provoke that which they’re afraid of.

VY: I had the pleasure of getting to know you a bit making these videos with you and I must say you’re a funny guy. When you do these paradoxical interventions, there’s a humorous side to it that fits with your personality. But does that work for everyone? Can therapists who have more sober personalities find a way to play with this?
RW: I don’t know how much humor is required in these protocols, but it’s a resource that I have and we use what we have. The most important thing, I think, is the resource of making contact and getting rapport with people and you can do that from the very beginning; and then it’s trying to access curiosity. I don’t think you have to have humor in order to authentically invest in being curious about, “What will this do for you if you try this out?” You know, I do talk about principles, but this is psychotherapy and it takes some finesse to help someone. I think people who have a lot of training in psychotherapy know how to do some of that stuff.
VY: I know it’s very hard to make generalities in therapy, but do you have a typical length of treatment for certain types of disorders?
RW: We typically have a 12-session intervention for people with panic disorder but we’ve got new data published that they’ve brought it down to five sessions. If we can unbundle what we’ve been doing and go to that lowest common denominator for intervention, we can shorten things up. It takes longer with Axis II disorders because those are woven into the fabric of the personality, so even though we can create a protocol, and they can use that protocol, it may take months for them to finish off that work for themselves, versus somebody with panic disorder who, in a very brief period of time, can be up like a phoenix.The interesting research that’s being done now is on ultra-brief treatment of panic disorder—even of post traumatic stress disorder—where they have been able to put a protocol in place successfully in five sessions with somebody with PTSD, which seems pretty remarkable to me.

VY: But many therapists, whether they’re in private practice or some kind of agency or other setting, tend to see clients that are a mixed bag. They come in for relationship problems or work issues or some anxiety and depression and, whether they’re Axis II or just have general life problems, their anxiety disorder is only a part of the clinical picture. How do you use these techniques within the context of a longer-term therapy?
RW: When I do presentations for therapists who are treating clients with anxiety disorders—whether they have other comorbid disorders or not—I try to get them to think about how they can structure their sessions in such a way that clients leave each session looking for an opportunity to experience some degree of uncertainty and distress regarding the themes of their anxiety.That’s a pretty simple protocol for the therapist. It doesn’t take a rocket scientist to figure out how to do this work—look at me. It’s a difficult treatment, but it’s not a complex treatment

VY: What makes it difficult for therapists? What’s hard to learn about this?
RW: It’s difficult because you’re looking at somebody who’s been entrenched in their way of solving the problem for a long time. You’ve got a client who does not tolerate not knowing how things are going to turn out. You’ve got a client who, as they try to experiment with something you’re suggesting, must trust you and trust the protocol without knowing how it’s going to turn out.That is the difficulty, because the disorder doesn’t allow them to feel confident. And if you listen to clients when you talk to them as they’re intently trying to learn what you have to give to them, they’re looking for security in what you offer them. “I’ll be glad to do what you tell me to do as long as you’ll give me a 100 percent guarantee I’ll have zero symptoms ever again.” And that’s not going to work. Einstein said: ““You cannot solve a problem from the same consciousness that created it. You must learn to see the world anew.” That’s the thread that runs through all of the treatment.

VY: I would imagine it’s also hard for therapists because they’re natural caretakers, they’re empathic, they want their clients to feel better…
RW: We do have this tendency in our field to keep rapport and be gentle, to not get people too upset. I think a lot of people gravitate to the treatment of anxiety disorders because they have an affinity to that arena. They know what it’s like to be anxious, they may have anxiety problems themselves, they’ve figured out some techniques and want to help others with it. But this is a contact sport. It’s aggressive. It works better when you’ve got a therapist who is already a risk taker.

This is a contact sport. It’s aggressive. It works better when you’ve got a therapist who is already a risk taker.

It’s like the primary care physician who’s trying to help you decelerate from a benzodiazepine that you’re dependent on. When they’re really kind and gentle with you, it sometimes takes forever to get off of them. When they’re a little tougher with you and push, then sometimes it works out better for you.

VY: So you need to be comfortable pushing a client into discomfort.
RW: That’s right.

The Meaning of Anxiety

VY: Existentialists such as Rollo May, who wrote the classic text, The Meaning of Anxiety, and other existentially-oriented psychotherapists would and have argued that there’s meaning in anxiety and we can learn about ourselves, about life, have insight, by delving into it—that it’s not something that should be brushed aside. Do you think that there’s meaning in anxiety?
RW: Well it’s fine to look at it that way, and on an individual-to-individual basis you may have to delve into that. But it does not mean that someone has to continue to express their anxiety in such a primitive fashion. People with panic disorder are expressing conflict very primitively. I certainly believe with panic disorder—and I’ve written about this—that there are benevolent purposes of the symptoms. And to look at those and understand those are helpful, but once we understand them, let’s negotiate another way to get those needs met.
VY: What are the benevolent purposes of the symptoms of panic disorder?
RW: It’s often to keep from being abandoned. There’s some data that a certain percentage of people with panic disorder suffered early childhood loss. Let’s say my father died when I was four, and my mother got severely depressed and laid on the couch every day. There are a lot of ways that I would have learned to cope as a child with that kind of loss. As I grow up, that stuff, existentially, kind of becomes who I am in the world. If my mother turns away from me because my dad left or my father left and never talked to me about why he left, I begin to think that I am not worthy as a human being. What parent, who loves his child, would abandon his child? There must be something inherently wrong with me. Some people with panic disorder use it unconsciously to maintain relationships so that their partner, their parent, whoever, won’t abandon them. That’s a benevolent purpose.
VY: So there’s secondary gain in that.
RW: That’s kind of a derogatory term, but it’s something like that. If we can step back and look at how the unconscious might have stepped in to take care of me, based on my belief about who I am from long ago, then there is a benevolent purpose behind why it showed up.I had a patient who came to me with OCD. She had two children with a workaholic physician who didn’t help with the kids at all. Her biological clock was ticking. She wanted to have another baby, but was concerned about her ability to take care of three kids instead of two. One day, she saw her son chasing her daughter with a kitchen knife and instantly she developed obsessive-compulsive disorder. She couldn’t stop thinking, “Oh my God. Could I hurt someone with a kitchen knife?” She had to get rid of all the knives in the house, everything sharp, all the scissors; no children could come over and be in her home for fear she would harm them. And of course, she was then too sick to have another baby.

So that’s another example of a benevolent purpose of the disorder. I think we do want to look around for some of those things and begin to take care of those, too. If the unconscious is driving some of this stuff that we aren’t aware of, then we’re going to have trouble helping people get better. The other definition of “strategic treatment” is doing whatever is necessary to help somebody get better. So if we need to do some family therapy or psychodynamic work or couples work or Sullivanian work—whatever it takes to help them turn the corner.

VY: It’s nice that there are cognitive-behaviorists who acknowledge unconscious psychodynamics. You’re very integrated. It seems like you really strive to hone in on what works.
RW: I hope that’s true. We just got some new data that suggest that that can help people more rapidly change their relationship with the disorder. We just did a study of people with obsessive-compulsive disorder going through this protocol, 80 people at a time, for two days. And the changes that took place were pretty remarkable, in terms of the measurements of the reduction of their obsessive-compulsive disorder and in altering their beliefs.If you just think about OCD being one standard deviation beyond the mean, where people get so totally caught up in obsessions and rigid belief systems, it’s quite amazing that we can bring about lasting change after only a few days.

Getting to “Aha”

Some folks have done some interesting research on what we called “applied relaxation,” which is learning relaxation skills and applying them to a variety of situations. In six sessions of an hour and a half each, then another six sessions of 45 minutes each, with practice homework throughout that time period, the major thing that these people changed after all this work was their beliefs.

If that’s true, then

I think we should be leading with belief change instead of leading with interventions that require a great deal of time to give someone insight and then for them to go, “Aha.”

I think we should be leading with belief change instead of leading with interventions that require a great deal of time to give someone insight and then for them to go, “Aha.” That’s how exposure and response prevention happens. We’re going to run them through this protocol until weeks or months later they go, “Oh, I see now. I don’t have to do my compulsion to get rid of my obsession.” Can we speed that up? I think we can.

VY: Final question. What advice would you give for students or early career therapists treating this population? Any pearls of wisdom?
RW: Look for any way to sit in on someone doing treatment with someone using these kinds of protocols. See how this works. That’s part of our motivation to get these anxiety disorder videos out there, so that people can immerse themselves moment-by-moment in this protocol. Whenever I do a workshop to teach these skills for therapists, it would be totally and completely fine for clients to be sitting in on the workshop as well because they can understand it just as easily.When I was in training and working with couples or borderline personalities for the first time, I’d go into supervision and say, “Okay. She said this. Now what do I say?” And he would help me figure that out. And then I would say, “Yeah but what if she responds like this? Then what do I say?” It can be daunting if you’ve not done this and observed it directly.

VY: Well I have always felt that we are a strange profession. You wouldn’t have dental students read about doing a filling and then send them off to do it without watching someone and then come back a week later to meet with a supervisor in a closed room and try to recall how they did their fillings. In fact, that was one of the reasons I started making training videos in the first place.I’m grateful that you consented to have your sessions recorded and I’m excited to release them and make them available for people who want to learn about the innovative approaches that you developed. So thank you so much for taking the time to go into this level of detail.

RW: Well, thank you as well for giving me the opportunity.

Eda Gorbis on Body Dysmorphic Disorder

Posted on by Psychotherapy.net Team

Characteristics of Body Dysmorphic Disorder (BDD)

David Bullard: To begin, could you give us a little background on BDD for our readers who may not be familiar with it?
Eda Gorbis: I began learning about treatment for obsessive-compulsive disorder (OCD) when I was helping to create day treatment protocols at UCLA Neuropsychiatric Institute in 1992, and then I furthered my knowledge by studying with Dr. Edna Foa in 1994. In 1996, I began work with a patient who had both OCD and BDD and was addicted to plastic surgery procedures. After successful treatment that was specifically designed to ameliorate the stress associated with her BDD, we were able to work with her on her remaining OCD, and my interest grew in this patient population.

Body dysmorphic disorder is self-perceived ugliness. It is when a person feels ugly inside about a minute anomaly—usually invisible to the naked eye of another—or has a markedly excessive preoccupation with even a slight defect, together with the feeling of being unable to make it right.

DB: So it’s a feeling and self-perception. I’ve noticed that, for some people with BDD, there is a vivid visual picture in their minds. One study highlighted the intrusive visual imagery these people have in addition to negative self-cognitions and feelings.
EG: When they look into the mirror, they see themselves as ugly.
They do not perceive themselves in the mirror as we perceive ourselves. They see a distortion that is invisible to others.
They do not perceive themselves in the mirror as we perceive ourselves. There is something wrong in their visual fields, from the eyes into the brain, that gives them inaccurate feedback. They see a distortion that is invisible to others.

What people with BDD perceive is actually similar to the reflection we have all seen in carnival funhouse mirrors. This differs from the common feelings of insecurity or self-consciousness about one's appearance that most people experience from time to time. Many people who have had cosmetic surgery are happy with the results and can move on with their lives without continuing to obsess about the original defect. With BDD, however, any surgical "correction" will itself be seen as imperfect, or an obsessive fixation with another body part will take over.

There are some theories, but the specific causes of BDD are not known. Many experts agree that sociological and biological factors play a role in the development of BDD.

DB: And it can be extremely debilitating.
EG: Yes, one of the most disabling conditions I know of. People experience extreme self-consciousness, and often avoid social situations, feeling others are judging and criticizing their self-perceived imperfections. The more the fixations intensify, the more it seems rational that others are also focusing on the “defect.” It can be a kind of paranoid ideation.

Then a person’s relationships suffer, along with many aspects of daily life. They can repeatedly request reassurances from others, but with no relief from their certainty about the ugliness. These compulsive requests for reassurance actually reinforce the false belief system and fixations; this leads to further compulsive questioning in a continuing cycle. They get so focused on their appearance that much time is spent hiding or trying to perfect the “flaw” cosmetically. These people are often unable to leave the house to make appointments, or to hold a job.

DB: Can you tell us about co-morbidity?
EG: BDD has a high co-morbidity with other anxiety disorders. The research is not perfect, but it seems that more men are treated for BDD than women. Perhaps female BDD symptoms are more likely to be interpreted as "normal" female behavior in our culture and are likely to be overlooked and remain untreated. The onset of BDD is not exclusive to a particular age, though symptoms often emerge during the teen-age years.

Treatment Considerations

DB: Could you give our readers an idea of how you work with someone with this particular disorder?
EG: More often than not, BDD is intertwined and co-morbid with OCD. Both disorders must be targeted at the same time—the perfectionistic concerns or fear of being criticized on a performance level that are characteristic of OCD, and also elements of social phobia that are associated with BDD.

BDD has certain expected features: for example, an exaggerated physical anomaly would be chin, eyelids, cheekbones—oftentimes in males, it would be penile size—with symmetry and exactness issues. I have found that women compare and contrast their breasts or their arms—any body part can be compared with the corresponding part on the other side of the body. The self-perceived anomaly also has a tendency to move from one body part into another: it can shift from the nose into the ear, for example.

DB: You mentioned that the first patient you worked with had had multiple surgeries. That’s a good example of how it shifts from one body part to another, and they get the surgery based on that.
EG: Right. That patient had more than a hundred cosmetic surgery interventions.
There is an element of addictive behavior and impulsivity associated with BDD, which can be a great warning sign for the clinician.
There is an element of addictive behavior and impulsivity associated with BDD, which can be a great warning sign for the clinician, because you do not find this so much in strictly obsessive-compulsive disorder. Some of the patients with BDD have also met diagnostic criteria for sexual addiction and gambling. It is the exact opposite for people with OCD. Patients with OCD are not impulsive. They would be like Rodin's "Thinker."

With patients with body dysmorphic disorder, you have an overlap between impulsivity and compulsivity. Whereas people with OCD are extremely moral and truthful, people with this overlap of impulsivity and compulsivity would show no guilt or remorse. This overlap makes treatment extremely challenging. Some patients with BDD have also met diagnostic criteria for sexual addiction and gambling, which was a little bit surprising to me. Well, not really surprising, but interesting how impulsivity and the pleasure is associated with the alleviation of tension or excitation. For example, in gambling, it's not the reduction of anxiety that is the aim of the behavior. The aim is the attainment of tension release, like hair pulling or when they squeeze pimples, and excitation—the adrenaline rush in gambling or sexual addition. So you have very different aims of the behaviors that are intertwined in very complex ways.

DB: Some of the people who have written in the field make a distinction between delusional versus nondelusional BDD—for instance, someone who looks in the mirror and sees that his ears are too big, and he really thinks that they are too big, versus someone who looks in the mirror and knows he feels bad about it but accepts reassurance. He knows that his ears are really okay, and he recognizes that he has a problem in his perception. Do you see that distinction? Is it helpful to you in your work?
EG: Let's call it poor insight. That is a better term than "delusional." And it is classified along with other OC-spectrum disorders, such as Tourette's syndrome, eating disorders, trichotillimania, and compulsive skin picking. BDD is also often seen as part of the impulse control disorders—where impulsivity can be thought of as seeking a small, short-term gain at the expense of a large, long-term loss. People with BDD get completely dysfunctional, as I described earlier-becoming addicted to surgical procedures, getting stuck in front of mirrors, needing to ask constantly for reassurance, etc.

Cognitive-behavioral therapy

DB: Although each case is individualized, can you give us an overview of how a cognitive-behavioral approach can be utilized in treating OCD?
EG: With cognitive-behavior therapy (CBT) a person learns to change the way he or she thinks and acts. We know different people can have different attitudes about the same specific conditions: A large facial birthmark can certainly be noticeable to others, but may have no negative impact on someone who has accepted it, while being debilitating to someone with BDD. And, of course, even a nonexistent or minor flaw can be devastating to a person with BDD. It is important to help people change their thinking habits. Exposure and response prevention are taught to people with BDD to help them face their anxiety and any co-morbid BDD concerns. This means repeatedly learning to tolerate discomfort. Anxiety gradually subsides as they continue to confront situations without the avoidance response.

We also use the 4-step model of our colleague Jeffrey M. Schwartz, MD, as
outlined in his books Brain Lock and You Are Not Your Brain: The 4-step solution for changing bad habits, ending unhealthy thinking, and taking control of your life.

The steps we teach our patients to help them get freed from obsessional thinking are:
Step 1: Relabel (recognize that the intrusive obsessive thoughts and urges are the result of OCD).
Step 2: Reattribute (Realize that the intensity and intrusiveness of the thought or urge is caused by OCD).
Step 3: Refocus (Work around the OCD thoughts by focusing your attention on something else, at least for a few minutes: do another behavior).
Step 4: Revalue (Do not take the OCD thought at face value. It is not significant in itself).

The Role of Psychoeducation

DB: Yes, I've found that simple process very useful for some OCD clients, and it goes along with my favorite bumper sticker: "Don't Believe Everything You Think!"
How helpful do you find psychoeducational materials?
EG: I think psychoeducational materials are always very helpful and important, because then patients know they are not alone. In fact, we now believe 5 million Americans are afflicted with this very debilitating illness. It removes a lot of people from the workforce.
We now believe 5 million Americans are afflicted with this very debilitating illness. It removes a lot of people from the workforce.
DB: Isn’t it a characteristic of BDD that it feels so shameful that the majority have hidden it from the people who are closest to them?
EG: Well, the dysfunction is most often extreme, and usually afflicts young people by the time they are 18 and ready to get out of the house and into college. Then, because of the self-perceived ugliness, they are unable to get into social situations or attend lectures. They can't date. They camouflage themselves with glasses and excessive makeup. It is similar to an anorexic who is quite underweight and having cardiac problems and broken bones, and losing consciousness and so forth, but still worries that she's too fat. These people, in a very similar way, feel ugly, and there is a delusional component to this feeling ugly, as in anorexia. A distinction from anorexia, however, is that an individual with BDD would be preoccupied with the appearance of his or her face, while the anorexic will be more preoccupied with self-control strategies regarding weight and shape.
DB: Can you recommend some books for therapists who want to learn more about this disorder?
EG: The classic in the field of BDD is Dr. Katharine Phillips' The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder (2005). She also has a newer one: Understanding Body Dysmorphic Disorder (2009). I have already mentioned the books of Dr. Schwartz. Other good ones are Feeling Good About the Way You Look (2006), The BDD Workbook (2002), and The Adonis Complex (2000).

We also have information on our website: hope4ocd.com. There are some other good ones such as Dr. Phillips' at www.butler.org; and the Massachusetts General Hospital BDD clinic; and www.bddcentral.com.

Mirror Externalization

DB: On the treatment end of it, would you say something about the mirror approach to your work?
EG: Because the physical anomaly is so exaggerated in the minds of these patients, I was thinking one day, "How do we externalize this self-perceived ugliness?" And I thought of the carnival funhouse mirrors, because they really exaggerate everything. It's a form of exposure. So we have a laboratory at the Westwood Institute in which a certain part is exaggerated when they're looking into a mirror. The room also has lighting controls, because different lighting and angles change our perception of the reflection. At this time the patients are just writing their anxiety levels.

We then cover all the mirrors for three days in a row, and all violations are recorded to track the compulsion. Compare-and-contrast behaviors—with those around them or with photos in magazines—are also counted as compulsive because they're done out of the anxiety. Or asking for reassurance: "Do I look good?"

The process of "externalization" works by causing the breakdown of maladaptive associations and repetitive manipulation of their external, material icons. In exposure therapy, BDD patients are provided with a symptoms list and must then induce the debilitating condition and self-monitor/rate objective signs, such as pulse rate, extent of nausea, dizziness, and cognitive distortions—for example, "My nose and forehead are too big." Cognitive restructuring through writing exercises and observational records are emphasized.

Our patients stay in the program from six to eight hours a day, and there are three clinicians working with them in shifts on a daily basis. After they work with the clinicians, I expose them in a controlled way to a regular mirror where they have to write a self-description, like someone in the police department is looking for them—a profile with no emotion associated with it.

We use cognitive-behavior therapy (CBT) with exposure and response prevention, and add mindful awareness training, cognitive restructuring, and Socratic questioning. We also use videotaping. Very often, I will use makeup artists to do an exaggerated prosthetic part. We have an interdisciplinary team. Treatment is tailored to each case. We also have six psychiatrists associated with us, who are OCD and anxiety disorder specialists.

DB: You have mentioned in the past that the model most clinicians have in private practice of the 50-minute session once or twice a week is inadequate for extreme cases of powerful dysfunctions such as BDD. It is wonderful that you are able to do such intensive work with those who are suffering with the most severe cases.
EG: We are able to do this work because we specialize only in OCD and BDD and other anxiety disorders. We don't treat anything else. And because of this narrow specialization, it is possible for one patient to work with three or four clinicians in a day. However, insurance companies just rejected one BDD case because they still don't accept the necessity for this intense treatment—they think it can be treated once a week, although this particular patient had been treated unsuccessfully once a week for years. It is a very debilitating illness—far more severe, I think, than OCD.

Medication

DB: That brings us to the issue of medications. SSRIs have been often prescribed to people with BDD. Would you say the majority of these people you work with are already on SSRIs, or do they end up on SSRIs?
EG: Based on my work with the six psychiatrists at the Institute, SSRIs alone do not seem to be helpful. There is no scientific evidence at this point for what really works with body dysmorphic disorder because of the delusional component and extremely poor insight. For people with high baseline anxiety, medication may be targeted to reduce anxiety. Depression and panic attacks can also be addressed with some medications, and atypical psychotic medications have also been used. But I have to emphasize that some kind of effective therapy is required, such as cognitive-behavioral therapy tailored to the individual case.

Families can also be a crucial part of the treatment.

It is important that family members see that this is a true debilitating disorder, rather than merely shallowness and self-absorption.
It is important that family members see that this is a true debilitating disorder, rather than merely shallowness and self-absorption. The love, support, and understanding of the family are very important, and they also have to be educated in how not to reinforce the obsessing and compulsions. Then, it is also important where they go after the treatment program.

Post-Treatment Care

DB: What are your experiences with post-treatment care?
EG: There are few referral possibilities for BDD patients to follow through. I think that these people are extremely high risk for relapse—maybe even more so than obsessive-compulsives, who have much greater compliance levels. Because of the impulsivity characteristic of BDD, you have less compliance, so even if patients do extremely well during the program, it is necessary to continue the self-therapy and self-treatment, because this illness is not really cured. I oftentimes give my patients examples: you can go through the best weight-loss program in the world, but if you then resort to your old eating habits, everything is going to come back right away. So really, I think it depends on finding out their interests or what they're best at while they're in the program, so that these dysfunctional compulsions can be immediately replaced with other activities. I tell them, "I don't care if you study Chinese, take a cooking class, or paint your house, as long as you get up in the morning and get going." Otherwise, all of the compulsions have a tendency to come back if the patients don't do anything that is productive.

Specialty Training in BDD

DB: I can see how important it is that they really understand what you're telling them about exposure and response prevention, and not reinforcing those dysfunctional behaviors. For any of the clinicians reading this who want to get the specific training needed to work in this arena, are you doing any training at the Westwood Institute or at UCLA?
EG: I would think that it's very important for them to go through training, but it would have to be hands on. It takes me approximately six months to train a good clinician for complicated cases, but I do specialize in extreme cases—patients who have failed a few other programs. Perhaps even a month of training would be sufficient if the clinicians saw a couple of cases that they would have to really work with intensively, because of the tailoring to the individual needs. It is not a cookie-cutter training; I couldn't tell you, "Here is a cookbook for any BDD case." Each case is like a snowflake. I've never seen two that were exactly alike, so we duly tailor the treatment to the individual needs of the patient.
DB: Absolutely. Finally, could you say something about the satisfaction you’ve gotten as a clinician in being able to help people who have experienced such terrible suffering and misery?
EG: My satisfactions are now taken with a grain of salt. Ten years ago, I was far more optimistic about the outcomes. I know now how debilitating and co-morbid this is with other illnesses, and how "feeling good" is dangerous for them. People with BDD have to be alert and vigilant to not fall into their old habits of dealing with their anxieties.

It's a medical illness that is extremely serious—like tremors of the mind. You could compare it a stroke or cancer that must be attended to. It is chronic; it waxes and wanes. People can definitely get to completely functional levels provided they attend to it on a daily basis. But, like a person with extremely high blood pressure or diabetes or even cancer, that person must be mindful and aware that there's a problem. Lately I've seen a few cases that had been in remission for 10 or 12 years and then they relapsed. I cannot tell you why. I don't even know if I have a hypothesis about the relapse after years in remission. And it sometimes takes longer to get them out of the condition the second time.

DB: That’s a very sobering indication of the great suffering and difficulty of having this disorder. I really appreciate your helping these people even without necessarily always having easy answers. On the other hand, I know of some people over the past several years that have made tremendous improvement in their functioning, even if they’ve had to come back and see you periodically. It’s made a big difference in the quality of their lives.
EG: I appreciate that, but the truth is I want to warn people against being extremely optimistic. There is no cure, and even if we ourselves have some of the highest levels of successful outcomes, let’s not forget that I’m extremely careful, having been trained by Dr. Foa to assess cases for hours and hours and to administer up to 15 tests to make our understanding of the individual even more precise. We also need to reject and refer elsewhere about 50% of the cases that come to us that I think we cannot help. People who come here are self-selected. We never have more than three cases at a time in the entire Institute, and we are able to pay a lot of personal attention to each individual and tailor the treatment. If something is not working from yesterday to today, we change it. We have that luxury. If I need to, I can dedicate the entire Saturday to this patient. That said, I don’t think other therapists have that luxury, and I think it’s very important to put this element into the level of success. It was never the quantity but the quality of the work that we have been focused on.
DB: I think that's one clear understanding that your patients have about your work—the intense dedication. Without being able to promise success, you are certainly one of the most dedicated people I know working in this challenging field
EG: You are most welcome.