Mastery of Obsessive-Compulsive Disorder Client Workbook

Transcription

1 Mastery of Obsessive-Compulsive Disorder Client Workbook Edna B. Foa Michael J. Kozak

2 Copyright 1997 by Graywind Publications Incorporated. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission in writing from the publisher. Permission is hereby granted to reproduce the Practice Records in this publication in complete pages, with the copyright notice, for instructional use and not for resale. The Psychological Corporation and the PSI logo are registered trademarks of The Psychological Corporation. TherapyWorks is a registered trademark of The Psychological Corporation. Printed in the United States of America A B C D E

3 Contents Chapter 1: Understanding Obsessive-Compulsive Disorder Introduction What Is OCD? Case Example: Concern With Dirt and Germs Case Example: Concern About Harming Others Types of OCD Washing and Cleaning Checking Repeating Ordering Hoarding Thinking Rituals Pure Obsessions Do You Have Obsessive-Compulsive Disorder? How Common Is OCD and What Is Its Course? What Other Disorders Are Related to OCD? What Causes OCD? How Are You Coping With Your OCD? Treatment Options Medication Exposure Therapy Should Behavior Therapy Be Combined With Drugs? Are You Taking Non-SRI Medications? What Benefits Will You Receive From Your Program? What Price Will You Pay? Chapter 2: Identifying Your Obsessions and Compulsions Obsessions Distinguishing Obsessions and Compulsions From Other Psychological Problems Should You Seek Professional Help? Chapter 3: Understanding Cognitive-Behavior Therapy for OCD What is Cognitive-Behavior Therapy for OCD? What Is Exposure? What Is Ritual Prevention? iii

4 Why Should You Do Exposure and Ritual Prevention? Emotional Involvement During Exposure Exercises Chapter 4: Designing Your Program Beginning Your Program Setting Up Your Imaginal Exposure Exercises Planning Your Imaginal Exposure Exercises Planning Your Actual Exposure Exercises Planning to Stop Your Rituals How to Monitor Your Rituals Sample Guidelines for Stopping Rituals Setting Aside Time for Your Program Scheduling Time for Your Program Informing Family and/or Friends Selecting a Supportive Helper Beginning Exposure and Ritual Prevention Chapter 5: Model Exposure Programs A Model Exposure Program for Washing Rituals An Intensive Exposure Exercise Schedule for Washing A Nonintensive Exposure Exercise Schedule for Washing A Model Exposure Program for Checking or Repeating Rituals An Intensive Exposure Exercise Schedule for Checking/Repeating A Nonintensive Exposure Exercise Schedule for Checking/Repeating Getting the Most Out of Exposure for Checking/Repeating A Model Exposure Program for Hoarding Rituals An Intensive Exposure Exercise Schedule for Hoarding A Nonintensive Exposure Exercise Schedule for Hoarding A Model Exposure Program for Ordering Rituals An Intensive Exposure Exercise Schedule for Ordering A Nonintensive Exposure Exercise Schedule for Ordering What to Do About Mental Rituals Chapter 6: Getting the Most From Your Program Developing the Courage to Confront Feared Situations Dangerous Beast or Paper Tiger Confront the Most Distressing Situation Early Planning for the Most Difficult Exposure What Is Courage? Risk Taking Introducing Intermediate Exercises Coping With Problems Unrelated to Exposure Ways to Address Slow Progress iv

5 Chapter 7: Extending What You ve Learned to Everyday Life Returning to a Practical Routine Do You Need Guidelines for Everyday Practices? Chapter 8: Maintaining Your Gains Principles of Self-Exposure Methods for Coping With Stress Informing Your Family and Friends Finding New Activities to Fill the Space Left by OCD v

6 Acknowledgments In clinical science, we extend our scope by standing on the shoulders of those who have preceded us. We owe much to the work of those who pioneered the application of behavior therapy to OCD, such as Meyer, Marks, and Rachman. Our conceptualization of emotional processing in exposure therapy has been greatly influenced by the bio-informational theory of Peter Lang, another trailblazer. Our many colleagues in research and practice over the years have also contributed to the development of our cognitive-behavioral approach. We are especially indebted to our clients with OCD, whose courage in confronting their obsessive fears has revealed so clearly the potency of exposure treatment, and to the National Institute of Mental Health, which has been supporting our research on OCD for almost 20 years. Our appreciation is extended to various persons at The Psychological Corporation, especially for the support we have received from John Dilworth, President; Joanne Lenke, PhD, Executive Vice President; and Aurelio Prifitera, PhD, Vice President and Director of the Psychological Measurement Group. The expertise contributed by Larry Weiss, PhD, Senior Project Director, has been invaluable in ensuring the high quality of the Therapist Guide. Special thanks are extended to those individuals whose meticulous and diligent efforts were essential in preparing the Guide for publication. Among this group are John Trent, Research Analyst; Kathy Overstreet, Senior Editor; Peggy Lang, Consulting Editor; and Javier Flores, Designer. vi

7 Comments Drs. Foa and Kozak have presented a masterful approach to the cognitivebehavioral treatment of obsessive-compulsive disorder. Building on their pioneering work in this area, they show clearly how to assess and treat OCD patients having a wide range of OCD symptoms. As importantly, they include the subtle steps that distinguish expert from merely adequate behavior therapists. Their discussion of how to proceed when treatment is not going well is worth the price of the book alone. Beginning and expert behavior therapists will learn a great deal from this program; I cannot recommend it highly enough. John S. March, MD, MPH Director, Program in Child and Adolescent Anxiety Disorders Duke University Medical Center Cognitive-behavioral therapy is increasingly being recognized as one of the most useful forms of treatment for obsessive-compulsive disorder. Drs. Foa and Kozak are the acknowledged experts in the field. They do research and write papers that guide other professionals. Now they have written a wonderful workbook for clients who want to overcome OCD. This is a must for anyone affected by OCD, as well as their family members and friends. Michael R. Liebowitz, MD Professor of Clinical Psychiatry College of Physicians and Surgeons Columbia University Director, Anxiety Disorders Clinic NYS Psychiatric Institute vii

8 About the Authors EDNA B. FOA, PhD, professor at the Allegheny University of the Health Sciences (formerly Medical College of Pennsylvania and Hahnemann University), Director of the Center for the Treatment and Study of Anxiety, is an internationally renowned authority on the psychopathology and treatment of anxiety. Her research aiming at delineating etiological frameworks and targeted treatment has been highly influential, and she is currently one of the leading experts in the areas of obsessive-compulsive disorder and phobias. The program she has developed for rape victims is considered to be the most effective therapy for post-trauma sequelae. More recently she has been investigating the psychopathology and treatment of social phobia. She has published several books and over 100 articles and book chapters, has lectured extensively around the world, and was the chair of the OCD work group and co-chair of the PTSD work group of the DSM IV. Dr. Foa is the recipient of numerous awards and honors, including the Fulbright Distinguished Professor Award, the Distinguished Scientist Award from the Scientific section of the American Psychological Association, the First Annual Outstanding Research Contribution Award from the Association for the Advancement of Behavior Therapy, and the American Psychological Association Award for Distinguished Scientific Contributions to Clinical Psychology. MICHAEL J. KOZAK received his PhD in clinical psychology at the University of Wisconsin-Madison in He is currently associate professor of Psychiatry at Allegheny University of the Health Sciences and Clinical Director at the Center for the Treatment and Study of Anxiety. He has studied the process and outcome of psychosocial treatment and pharmacotherapy for anxiety disorders, including blood/injury phobia, obsessive-compulsive disorder, post-traumatic stress disorder, and social anxiety. His expertise in exposure-based treatment for obsessive-compulsive disorder has been developed over 14 years of daily clinical practice with OCD sufferers. His scholarly publications include reports of individual case studies and controlled outcome trials of cognitive-behavior therapy and pharmacotherapy for anxiety disorders, laboratory psychophysiological studies of emotion, theoretical and review articles, and philosophical analyses. He was a member of the workgroup on Obsessive-Compulsive Disorder for the DSM IV. viii

9 Chapter 1 Understanding Obsessive-Compulsive Disorder Introduction This workbook will help you recognize symptoms of obsessive-compulsive disorder and develop and put into practice a program of exercises to reduce these symptoms. What Is OCD? Obsessive-compulsive disorder (OCD) appears as a set of habits which are called obsessive-compulsive symptoms. These are habits of thinking, feeling, and acting which are extremely unpleasant, wasteful, and difficult to get rid of on your own. Usually, these habits involve thoughts, images, or impulses which habitually come to your mind even though you don t want them. Along with these thoughts, you have unwanted feelings of extreme discomfort or anxiety and strong urges to do something to reduce the distress. For example, a person might have the idea that he is going to get sick from certain germs or cause harm to others by not being very careful. These ideas cause the person extreme distress. Because of this, people get into the habit of thinking various special thoughts or doing certain actions that protect themselves or others or simply reduce the distress. These habits are called rituals. Unfortunately, performing these rituals doesn t work all that well: The distress diminishes for only a short time, then comes back again. Often, you find yourself doing more and more ritualizing to try to get rid of the anxiety. But the rituals do not reduce the distress permanently, and before long you are putting so much time or energy into rituals (which do not work that well anyway) that other areas of your life become seriously disrupted. Do you feel dominated by your own intrusive worries? Do you feel compelled to repeat thoughts or actions again and again? Most people experience 1

10 bothersome worries from time to time, but they are not consumed by these concerns. For example, parents may often worry about the safety of their child who is late getting home from school, but for the most part, they are not incapacitated by such a concern, and it goes away when the child eventually arrives home safely. A person with OCD experiences worries that are neither so realistic nor do they go away so readily. For example, a mother may have an obsession that she will deliberately hurt her child. Such an obsession sometimes feels like an urge to do harm. The obsession dominates her experience persistently, even though she loves her child and has never deliberately harmed the child. Another very common feature of OCD is repeating actions such as washing, checking, and ordering or arranging of objects well beyond what is practically useful. Many people check door locks a couple of times upon entering and leaving to secure themselves against intruders, but such extra precaution occupies little time and effort and is of some practical utility. In contrast, a person with OCD may check the lock a great many times and continue to worry throughout the day about whether he has locked the door, despite all the checking. Some people with obsessive-compulsive disorder repeat things mentally. For example, a person may repeatedly think of self-designated lucky numbers, such as 3, 6, 12, and 18, to prevent bad things from happening. Do you have obsessions or compulsions? Do you get stuck with thoughts, feelings, or actions that are distressing and unwanted? Do you repeat behavior or thoughts again and again to try to rid yourself of distress? If so, you probably have obsessive-compulsive disorder. Case Example: Concern With Dirt and Germs There are many types of obsessions and compulsions. A common problem is concern with dirt or germs, accompanied by excessive washing and cleaning. Betsy is a 33-year-old married kindergarten teacher who is consumed by fears of dirt and germs. She worries especially that she will contract a venereal disease if she uses public toilets or even if she contacts another person who has used public toilets. Because most people, including her students, routinely use public toilets, she perceives everyone in her environment as contaminated. The obsessions make her daily life extremely difficult, because it is nearly impossible to avoid contact with her feared contaminants. To protect herself, Betsy keeps a bottle of alcohol with her at all times and repeatedly cleans her hands with it as unobtrusively as possible while she is at work. When she comes home, she immediately removes all her clothes and takes a 45-minute shower, repeatedly soaping herself thoroughly. To protect her home from toilet contamination, she also requires that her husband and two children observe strict rules about cleanliness. Although her young children are generally compliant with her rules, her husband has tired of his wife s unreasonable demands, and the marriage has become increasingly tense. 2

11 Betsy was especially concerned with cleanliness even as a child and was more meticulous than average through her teenage years. However, her concerns did not start to interfere seriously with her life until after she got married, when she began to devote quite a bit of time to cleaning the toilet at home. Around the time she became pregnant with her first child, she read that venereal disease can be passed by mother to child and became obsessed with this possibility. To prevent her newborn from catching the disease, Betsy began to avoid using public toilets and increased the effort devoted to cleaning her own bathroom. These measures did not give her an adequate sense of protection, however, because she realized that others were not as careful as she around toilets, and they could contaminate her by direct or indirect contact. At the time she came to the clinic, Betsy s lifestyle was severely restricted because of her obsessional fears. She had stopped inviting friends to her home and going to restaurants, theaters, and other public places. Most recently, she had been thinking about quitting her job because of her fear of contamination, but because she couldn t afford to give up her salary, she decided to seek treatment. Case Example: Concern About Harming Others Marvin is a 30-year-old accountant who is married and has a 2-year-old son. He works in the city and drives 45 minutes each way from his home in the suburbs. Marvin worries constantly about making mistakes that could cause harm to others. He is concerned not only for the welfare of other people but also for animals, even insects. These worries lead him to check endlessly almost everything he does. While driving, he thinks that he might have hit someone, so he checks his mirror for accidents and often drives back over his route to assure himself that no one is in need of assistance. He also worries about new accidents that he might have caused while retracing his route. After an hour or two of checking the roads, Marvin reluctantly gives up and drives home, but he continues to worry about being a hit-and-run driver. Marvin carefully checks toilets for insects before flushing, lest he accidentally kill them; before going to bed, he checks every door, window, electrical appliance, and faucet in the house to prevent disasters. At work, Marvin checks his calculations so often that he is always well behind the productivity of his co-workers. Marvin s obsessivecompulsive activities and worries occupy many hours per day, cause him enormous emotional distress, and impair his day-to-day functioning. Marvin recalls that his worries about mistakes began when he was about 15 or 16 years old and were focused especially on his schoolwork. He was very anxious about learning to drive, and he began to worry about hurting people unintentionally. This concern about causing harm eventually came to include animals and his personal belongings. Because he realized that his worries and checking were taking up too much of his time, Marvin consulted a psychiatrist, who said he had OCD and prescribed clomipramine (brand name: Anafranil ). The medication gave him some relief, but he was still spending too much time on his obsessions and compulsions. 3

12 If your experiences are like those of Marvin or Betsy, or if you have other types of obsessions or compulsions, this manual might be helpful to you. Types of OCD There are many specific types of obsessive-compulsive habits. Washing and Cleaning. Individuals who engage in washing and cleaning rituals are preoccupied with obsessions about being contaminated or contaminating others with certain materials or situations. Examples of contaminating materials are chemicals (such as insecticides), germs (such as HIV viruses), bodily fluids (such as urine and blood), and radiation (such as microwaves). Contaminating situations include cities (one s hometown), people (parents), and public places (hospitals). Sometimes washing and cleaning are intended to prevent disasters (e.g., disease, death), but this is not always the case. Some individuals wash and clean to reduce discomfort connected with a sense of contamination, but they do not believe that they will be harmed by the contamination. The time occupied by washing and cleaning varies from person to person and from one day to another. Some people engage in compulsive washing infrequently but continue the behavior for very long periods. Other compulsive washing may be very brief but occurs a great many times per day. Usually, people concerned with contamination try hard to avoid contact with their contaminants, but they usually fail sooner or later and resort to washing or cleaning. Checking. Individuals who carry out checking rituals try to keep bad things from happening by excessive and repeated checking of potentially harmful situations. Common concerns of people with this manifestation of OCD are that they will be responsible for fire, flood, hit-and-run auto accidents, mistakes of all kinds, burglary, and illness. For example, the person who fears that his house will catch fire checks whether electrical appliances are unplugged before he leaves home or goes to bed. The person who fears having undetected cancer performs frequent inspections of moles or breasts. The student who fears schoolwork mistakes repeatedly checks assignments to the point that they are not turned in on time. Usually the person feels an urge to check when there is some doubt about the safety of the situation. However, checking does not relieve the doubt, and more checking follows. The chain of doubting and checking can last for hours and typically ends, not because the doubt has been eliminated, but because of exhaustion or outside demands. Sometimes a person who engages in checking recruits other people to help with the checking. Repeating. Some individuals purposely repeat actions to cancel or undo a fearful thought that has come to mind. For example, 4

13 a person walking through a doorway who gets an image of a loved one having an accident will go back and forth through the doorway until the image disappears. The purpose of this repetition is sometimes not only to cancel the image but also to prevent the accident from happening. Other individuals repeat actions until the action feels right to them. In these cases, there is no thought of preventing harm, and the repetition is done to reduce discomfort about doing something wrong. Ordering. For individuals who engage in ordering behaviors, it is important to have things around them arranged in a certain way. Sometimes this means arranging items symmetrically or in some special pattern or location. As with repeating, the purpose of ordering can be to keep a disaster from occurring. For example, a person who feels compelled to arrange items might always set down glasses, pens, and other objects several inches from the edge of a table to prevent them from falling off and being damaged or lost. Not all ordering compulsions are done to prevent harm, however. Instead, a person arranges items in a way that just feels right. For example, if furniture is not lined up at the correct angles and cushions are not evenly spaced, the person becomes extremely uncomfortable. The individual with this type of OCD does not permit family members to upset the special arrangement. Hoarding. Individuals with hoarding behaviors collect things that seem useless to other people. Compulsive hoarding is different from collecting stamps, coins, or antiques that have real value or are part of an enjoyable hobby. Usually an individual with this form of OCD feels driven to collect things because of some remote chance that they might be of some use in the future. Most people save some things they really don t need, but they would discard the items if they began to get in the way. Individuals who hoard, however, often accumulate large quantities of junk that they view as important and find it very distressing to throw away. Thinking Rituals. Individuals who engage in thinking rituals use special thoughts, called thinking compulsions, to undo or cancel their distressing obsessive thoughts, impulses, or images. Compulsive thoughts are much like compulsive actions, but people carry them out in their minds rather than outwardly. Because of this, thinking rituals are sometimes overlooked or mistakenly believed to be obsessions. Common thinking rituals are silent counting and repeatedly thinking certain words, phrases, numbers, or special prayers. For example, a person with obsessive fears of street drugs will repeatedly replace any thought of the drug LSD with a thought of the letters RCA. Another kind of mental ritual is reviewing past events or lists of things to do. For example, after leaving the bathroom, a person who washes compulsively might review whether or not she touched any contaminated surfaces with her clothes. Some people 5

14 repeatedly go over in their minds lists of things to be done that day to make sure that they don t forget something important. Sometimes, obsessions take the form of an ongoing internal dialogue, with one side voicing distressing ideas and another side expressing reassuring thoughts. For example, a combat veteran thought constantly about whether he could have saved two friends who were killed beside him in battle. He repeatedly considered ways that he could have saved them and also repeatedly concluded that there was nothing else he could have done. The reassuring voice appears to be a mental compulsion. Pure Obsessions. A few individuals spend long periods of time dwelling on intrusive distressing thoughts but do not react to these with ritualistic thoughts or actions. For example, a person might think about a song or melody to the point that it becomes annoying. Alternatively, a person might dwell on particular kinds of objects (such as shirt buttons) or certain words and have found the intrusions very distressing and interfering with routine concentration. It is important to remember that individuals with OCD typically have more than one type of obsession and compulsion. For example, many individuals who engage in washing rituals also have checking or ordering rituals. Also, the same person often has both thinking rituals and behavioral rituals. Do You Have Obsessive-Compulsive Disorder? The diagnostic system for mental disorders that is used in the United States (Diagnostic and Statistical Manual of the American Psychiatric Association 4th Edition, or DSM IV ) identifies OCD as an anxiety disorder and defines it according to the criteria listed here. DSM-IV Diagnostic Criteria for Obsessive-Compulsive Disorder A. Either obsessions or compulsions: Obsessions as defined by 1, 2, 3, and Recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress. 2. The thoughts, impulses, or images are not simply excessive worries about real-life problems. 3. The person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or action. 6

15 4. The person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind (not imposed from without as in thought insertion). Compulsions as defined by 1 and 2: 1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly. 2. The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive. B. At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable. Note: This does not apply to children. C. The obsessions or compulsions cause marked distress, are timeconsuming (take more than 1 hour a day), or significantly interfere with the person s normal routine, occupational (or academic) functioning, or usual social activities or relationships. D. If another Axis I disorder is present, the content of the obsessions or compulsions is not restricted to it (e.g., preoccupation with food in the presence of an Eating Disorder; hair pulling in the presence of Trichotillomania; concern with appearance in the presence of Body Dysmorphic Disorder; preoccupation with drugs in the presence of a Substance Use Disorder; preoccupation with having a serious illness in the presence of Hypochondriasis; preoccupation with sexual urges or fantasies in the presence of a Paraphilia; or guilty ruminations in the presence of Major Depressive Disorder). E. The disturbance is not due to the direct physiological effects of a substance (e.g., drug of abuse, a medication) or a general medical condition. Specify if: With Poor Insight: if, for most of the time during the current episode, the person does not recognize that the obsessions and compulsions are excessive or unreasonable. Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Copyright 1994 American Psychiatric Association. 7

16 The central features of OCD are obsessions or compulsions that are seriously distressing or are interfering with day-to-day activities. In fact, research has shown that obsessions rarely occur without compulsions, and vice versa. Chances are that if you have obsessions, you also have related compulsive thoughts or actions or both. Often, obsessions provoke anxious or fearful feelings, but they can also prompt other distressing feelings such as disgust, shame, or guilt. A person concerned with getting sick because of contamination is likely to feel anxious or afraid in the presence of contaminants. Another person might feel mainly disgusted, rather than afraid, when he or she encounters a contaminant. A mother with an obsessive fear of stabbing her child would feel afraid of actually harming the child and also guilty about having such an unacceptable idea. A religious person who has an unwanted image of sacrilegious sexual activity might be overwhelmed with shame and guilt and could also be afraid of supernatural punishment. Whatever the emotion connected with the intrusive thought, image, or impulse, the emotion must be negative or unpleasant to be considered an obsession. Fear, guilt, disgust, and shame are all unpleasant emotions. Intrusive ideas connected with pleasant feelings are not considered part of OCD. For example, a person could have excessive thoughts or images about being rich, taking exciting vacations, or marrying a movie star. Although spending too much time on such pleasant fantasies could be a problem, this would be categorized as excessive daydreaming and is not a symptom of OCD. Obsessions have much in common with excessive worries. Both are thoughts that are accompanied by unpleasant feelings. However, obsessions are different in some important ways. Unlike worries that are experienced as appropriate but excessive concerns about real-life problems, obsessions are generally experienced as inappropriate. Often this difference is clear, such as the distinction between excessive worry about financial problems and an obsession about the possibility of having hit someone while driving. Sometimes the difference is not so clear, and only accompanying mental or behavioral rituals or compulsions distinguish the obsession of OCD from excessive worry. Compulsions, which can be behavioral or mental, are also called rituals. Mental compulsions are attempts to neutralize an obsession and are present only in people with OCD. Mental and behavioral compulsions can be further divided into two types: those that are done to reduce obsessional distress (such as washing to reduce fear of illness or to decrease distress about being contaminated) and those that are unrelated to obsessions (such as repeating an action until it feels right ). Research has shown that the majority of compulsions are related to obsessions. Sometimes it is difficult to tell the difference between compulsions that are not related to obsessions and complex motor tics, repetitive movements that are experienced as under limited voluntary control (such as tapping, rubbing, and eye blinking). Despite the difficulty, it can 8

17 be important to recognize whether a repetitive behavior is a tic or a compulsion, because the treatments for the two are different. A rule of thumb is that a tic is perceived as largely involuntary: The urge can be suppressed for a while, during which a feeling of tension builds, after which the tic must be expressed. In contrast, a compulsion is usually experienced as more voluntary, and the distress and urge to ritualize will fade after a time if the person refuses to perform the compulsion. Many people with obsessions suspect or believe that some disastrous consequence will occur if they do not perform their compulsions. Many recognize, at least some of the time, that the belief is mistaken. For example, when sitting in the therapist s office, a person who gets obsessions about causing hit-and-run automobile accidents can see that the concern is unrealistic. However, when the same person drives over a rut in the road on a dark evening, clear thinking is more difficult, and the person may jump to the false conclusion that the bump was a pedestrian. People who engage in washing because they fear catching venereal disease from public toilets may recognize, when they aren t near any toilets, that even if they do not wash their hands, they will not get sick. However, it can be much harder for them to recognize this when they are actually sitting on a toilet seat in a public bathroom. A small proportion of people with OCD very strongly believe that a disaster will occur unless they do their compulsions, such that the belief doesn t change much when the person is away from the situation that triggers the obsession. For example, one woman concerned with contracting leukemia believed that unless she successfully avoided or washed after contacting blood, radiation, and certain environmental toxins, she would definitely catch the disease. Now that you are familiar with the description of obsessions and compulsions in the DSM IV, you can consider whether you have OCD. Do you have obsessions, compulsions, or both? If so, are they very distressing? Do they interfere with your daily functioning? If so, do you fear certain disastrous consequences if you do not avoid or ritualize? Do you sometimes recognize that these concerns are unrealistic? How Common Is OCD and What Is Its Course? OCD is quite common. About six million individuals in the USA are estimated to have OCD. Men and women develop OCD at similar rates. It has been observed in all age groups, ranging from school-aged children to older adults. It typically begins in adolescence or early adulthood, usually starting earlier in males than in females, but it can also begin later in life. As a rule, onset is gradual, but in some cases OCD starts suddenly. Symptoms fluctuate in severity from time to time, which might be related to the occurrence of stressful life events. Because the symptoms usually worsen gradually, people often do not remember clearly 9

18 when the OCD began but can sometimes recall when they first noticed that the symptoms were disrupting their lives. Do you remember when your symptoms started, or when you found that they were actually getting in the way of things in your life? What Other Disorders Are Related to OCD? Certain emotional disorders are similar to OCD or often accompany it. Many people with OCD also experience depressed mood at the same time. Much of the time, the depression seems to have been caused by the OCD in that it is emotionally exhausting and demoralizing to suffer with OCD. In these cases, if the OCD decreases (either spontaneously or through treatment), the depression will also lift. Sometimes the depression is not caused by the OCD, as in cases where the depression began earlier than the onset of the OCD symptoms. If a person has obsessions only about being sick and consults physicians excessively but does not engage in other rituals such as checking or washing, the individual is said to have hypochondriasis. An individual with OCD may have both hypochondriacal obsessions and obsessions about things unrelated to health. A person who is generally anxious and has excessive worries about real life circumstances but not obsessions or rituals is said to have generalized anxiety disorder. Tics are commonly experienced by people with OCD. It has been estimated that about 20% 30% of clients with OCD also have tics. A tic is a sudden, rapid, recurrent, stereotyped motor movement or vocalization that is experienced as irresistible but can be suppressed for a while. If a person has motor tics in addition to one or more vocal tics, this is called Tourette s disorder. Thirty-five percent to 50% of people with Tourette s disorder also have OCD, but only 5% 7% of people with OCD appear to have Tourette s disorder also. Some scientists believe that trichotillomania ( compulsive hair pulling) is a form of OCD, but this may not be so. Even though most people with OCD have multiple obsessions and compulsions, those with OCD do not typically exhibit hair pulling. Therefore, hair pulling does not seem to go together with the compulsions of OCD. What Causes OCD? The reasons why some people develop OCD and others do not are unknown. Researchers have considered different kinds of explanations for the disorder. Some experts have tried to understand OCD as learned habits. Accordingly, a harmless object or situation becomes fearful because of a connection to a harmful one. Once this happens, escape (rituals) or avoidance patterns emerge naturally and 10

19 are maintained because they are partially successful in reducing fear. Although this idea does not explain why some people develop OCD and others do not, it fits well with how obsessions give rise to anxiety/discomfort and compulsions reduce it, and it helps to explain how the temporary reduction of obsessional distress could maintain habits of ritualizing. Other experts have suggested that some specific thinking mistakes about harm characterize OCD. Examples of such thinking mistakes include the following: (a) thinking of an action is just like doing it; (b) not trying to prevent harm to self or others is the same as actually causing the harm; (c) a person is responsible for harm regardless of circumstances; (d) not ritualizing to prevent harm is just like causing harm; and (e) a person should control his/her own thoughts. Although this theory may describe the kind of thinking mistakes made by many individuals with OCD, it does not explain why some people develop OCD and others do not. Many experts believe that people with OCD have abnormal brain chemistry involving serotonin, a chemical that is essential to brain functioning. Unusual serotonin chemistry has been found in people with OCD, and drugs that relieve OCD also change serotonin chemistry. However, it is not known whether serotonin chemistry is the key factor in the development of OCD. Some scientists have identified differences in the size and function of various parts of the brains of people with OCD. Whether these differences are important causes of OCD symptoms or are just coincidental is also unknown. There is evidence that OCD is more prevalent in some families than in others. It is difficult to know how much of this is a result of what children learn from their family while growing up, and how much is hereditary. Studies of twins suggest that at least some vulnerability to OCD is inherited. It is tempting to be overly concerned with the lack of information about how OCD develops, but this information is not required for treating the disorder. Fortunately, good treatments are available even though a thorough explanation of why some people get OCD and others do not get it is not available. How Are You Coping With Your OCD? 1. Mental resistance. Do you try to resist your obsessions? Because obsessions are unpleasant or distressing, it is not surprising that you would want to try to get the ideas out of your mind. When you have a thought that is not disturbing at all, or only mildly disturbing, and you want to think about something else, just turning your attention to what you want to think about is usually successful. When you are trying to get rid of an obsession, however, you don t just turn your attention to something else, but rather, you concentrate on not thinking about the obsession and on how bad it is to be obsessing. This way of fighting obsessions seems to backfire in that you find that the obsession becomes more persistent and annoying. 11

20 2. Avoidance. Are you avoiding situations that trigger obsessions? Another unsuccessful way of trying to cope with obsessions is to try to stay away from all situations that trigger your obsessions. There are three problems with trying to cope by avoidance. The first problem is that avoidance is only temporarily helpful because eventually you will encounter a feared situation that you cannot avoid, and the obsession will arise. Second, the more you avoid, the more you preserve your fear because you cannot find out that the situation is really not dangerous. Third, because there are so many situations that can trigger obsessions, avoiding them severely restricts your lifestyle. For example, a person who fears auto accidents might start by avoiding crowded areas at night, then all night driving, then daytime driving in crowded areas, and finally, all driving while alone. Many people with hit-and-run obsessions stop driving altogether. 3. Rituals. Do you use rituals to cope with your obsessions? Because avoidance doesn t work well in the long run for fighting obsessions, a person with OCD usually winds up facing distressing obsessions. Therefore, people resort to compulsions (rituals) to try to cope with the obsessions. There are two problems with rituals. First, like avoidance, rituals can be successful in the short run but backfire in the long run because they seem to make obsessions worse. The first reason for this is that the rituals prevent an individual from learning that no harm will come from the feared situation. For example, a person who cleans doorknobs for fear of getting sick from the germs on the doorknobs cannot discover that unwashed doorknobs don t cause sickness. Second, rituals generally expand and take increasing time and effort, to the point that they severely interfere with day-to-day life. Thus, instead of providing temporary relief, they can become distressing in themselves. For example, a person concerned with safety at home starts checking doors and window locks, then checks gas and electrical appliances, then all the faucets. Soon, one round of checking is insufficient, and several rounds are made. This can go on to the point that the individual does little at home beyond checking for safety. Do Your Symptoms Fit This Program? If you answer yes to the following questions, your symptoms probably fit the treatment program described in this book. Do you have obsessions? Do you have compulsions? Are they distressing enough to be important to you? Do they interfere significantly with your daily life? 12

21 Treatment Options There are two types of treatment that have been found helpful for OCD: cognitive-behavior therapy and medication. Both have been studied extensively with hundreds of clients in centers in different parts of the world, and both are established treatments for OCD. There are advantages and disadvantages to both types of treatments. Each treatment will be described here, along with its advantages and disadvantages, to help you make a choice. Medication Treatment with certain medications has been found to be quite helpful. Particular drugs called serotonin re-uptake inhibitors (SRIs), a class of antidepressant drugs, have shown effectiveness with OCD. It is not clear why they work, but it is clear that they do indeed often help to reduce OCD symptoms. When drug therapy is successful, obsessional distress diminishes, urges to ritualize decrease, and along with these, rituals and avoidance are also reduced. The frequency and persistence of obsessive intrusions also decrease as well, although most clients say that they still have some obsessive intrusions even after successful drug treatment. Several drugs that fall into the class of SRIs have been found helpful for OCD, and it is practical first to use only the ones that are approved by the FDA for treating OCD. Depending on the particular drug, the evidence is more or less strong for its helpfulness. The most well-established drug is clomipramine, whose brand name is Anafranil. Clomipramine has been studied with hundreds of clients, and about half of the individuals who take it do well with it, showing an average reduction in OCD symptoms of about 40%. Thus, you can see that clomipramine is a good drug: Half of those who take it improve enough that they say it makes an important difference in their lives. There are several other drugs recently approved for treating OCD: fluoxetine (brand name: Prozac ), fluvoxamine (Luvox ), paroxetine (Paxil ), and sertraline (Zoloft ). These drugs have also been studied very extensively and have been established as being helpful with OCD. It is hard to say with confidence which of the SRIs is best for OCD. Although a comparison of the available good studies of the different medications seems to show that clomipramine produces somewhat larger improvements than the other drugs, some studies done more recently have not found such differences. The drugs have the clear benefit that they are helpful for many people. They also have an advantage in that taking them does not require much effort. After a few psychiatrist visits, and once you have worked up to an effective dosage of the drug, you meet with your psychiatrist only occasionally for monitoring. Of course, these are averages, and in choosing a treatment, you are betting on averages. You could do much better than the average, or you might not improve at all with the drug. It is impossible to predict who will do well with a particular treatment and who will not. 13

22 What are the disadvantages of the drug therapy? First, even though many people do well with drug therapy, about half of those who take medication do not improve; and of those who do improve, most still experience noticeable OCD symptoms. In addition, drugs do not usually do only what you want them to do, which is to decrease OCD symptoms. They usually have some unwanted side effects also. These are readily tolerated by many people but can sometimes be unpleasant or intolerable. For example, side effects from clomipramine can include dry mouth, sleep changes, weight gain, and sexual dysfunction. Although you would probably experience some side effects, it is difficult to predict how tolerable they will be for you. One other disadvantage of the medications is that, although you will probably continue to do well as long as you keep taking the drug, many people who withdraw from medication have a return of OCD symptoms. Many people are not concerned about taking a medication for a long period, but some people prefer not to do this. (Women who wish to get pregnant are generally advised to withdraw from their medication because so little is known about how it may affect the pregnancy.) Exposure Therapy The other established treatment for OCD is a form of cognitive-behavior therapy called exposure therapy. This has also been studied very extensively with hundreds of clients in different countries and has been found very helpful. The theory behind exposure therapy is different from that behind drug therapy. With drug therapy, you ingest a chemical, it gets into your brain, changes your neurochemistry, and your experience improves. Cognitive-behavior therapy is based on the idea that obsessive intrusions, distress, and rituals are habitual ways of reacting, and because they are habits, they can be weakened. Exposure therapy is a learning-based therapy that consists of a series of exercises designed to weaken certain thinking habits, feeling habits, and overt habits. The exercises are called prolonged exposure and response prevention, which actually means abstaining from rituals. Exposure means that you purposely confront situations that trigger obsessions, distress, and urges to ritualize, and that you stay in the situation for a long period of time until the symptoms decrease spontaneously. Abstaining from rituals means that you give up using rituals as a way to reduce obsessions and distress. Excellent results have been obtained with an intensive cognitive-behavior therapy program that consists of daily 90-minute sessions for a month, including guided exposure practice with the therapist at your home. This is important because OCD habits are often especially strong in the home. In addition, this program involves daily homework practice with the exposure exercises and concentration on abstaining from rituals. There are some clear advantages to exposure therapy. It has been found to be more helpful than drugs for individuals who complete it. About 75% of clients who complete cognitive-behavior therapy do well both immediately after treatment and in the long run, showing lasting improvement of about 14

23 65% fewer symptoms on average. Additionally, you need not concern yourself with medication side effects from exposure therapy. There are some drawbacks to cognitive-behavior therapy that you should know about. First of all, just as with medication, there is no guarantee of improvement. Even though it is an excellent treatment, about one in four individuals who receive it do not benefit. Furthermore, even those who do benefit are not usually completely symptom-free. They do say, however, that the therapy made an important difference in their experience. Second, although one doesn t usually think of psychotherapy as having side effects, there is one unpleasant side effect of exposure therapy. This is the distress that occurs when you confront situations that provoke your obsessions. Typically, when a person first confronts a feared situation, the person reacts with distress, but this then decreases spontaneously over the course of a session. The next time the situation is confronted, the individual experiences less distress, and so on with repeated exposure practice until the situation prompts little distress. The distress is a side effect in that the goal of the therapy is really to reduce distress, but during the exposure practice, distress increases temporarily and is not something you want to experience from the therapy. If you choose the cognitive-behavior therapy, you should expect to experience distress during the exposure exercises. It is difficult to predict how uncomfortable you would feel: Some people are intensely distressed and others experience minimal distress. A third item to consider about the cognitive-behavior therapy is that it requires substantial effort on your part. Unlike the drug treatment, where a chemical does most of the work, in exposure therapy you do most of the work, practicing exposure both in sessions with the therapist and on your own for homework. Thus, for exposure therapy to work as well as it does, you must dedicate enough time and energy to practice. The payoff from this therapy depends heavily on your investment of time and effort in the program. This cost in your own time and effort can be seen as a disadvantage of exposure therapy, compared to drug therapy. In sum, there are two good treatments for OCD. Cognitive-behavior therapy seems to produce more improvement than medication, and these improvements are more lasting after treatment is stopped. Medication therapy takes less time and effort in the short run than exposure therapy but would probably have to be continued indefinitely if you are to keep your improvements. Exposure therapy is usually emotionally challenging and requires your determination to continue even when the exposure is distressing. Medication therapy is not so emotionally challenging but requires your willingness to tolerate various medication side effects. Should Behavior Therapy Be Combined With Drugs? Many experts recommend treatment with a combination of behavior therapy and medication. There is no evidence that, in the long run, such combination 15

24 treatment is generally better than behavior therapy alone. Although some findings suggest that combination treatment is superior to individual treatment in the short run, this has not been clearly established and may not be generally true. Individuals who find the prospect of behavior therapy too scary may consider taking one of the SRI medications in the hope that their symptoms will decrease enough that they will be ready to try behavior therapy. If you are currently being helped by an SRI medication and wish to start behavior therapy, you may want to continue the medication during behavior therapy and consider discontinuing the drug if a satisfactory result has been achieved with behavior therapy. Some individuals seek behavior therapy as an alternative to drug treatment, because they do not want to be taking the medication. If you begin or withdraw from medication as you start behavior therapy, you are changing two treatment factors (the drug and exposure therapy) at one time. This can make it difficult to distinguish the effects of one treatment from the effects of the other. For example, if you start taking an SRI and begin behavior therapy at the same time and you improve, it will be difficult to tell which treatment was more helpful. Alternatively, if you start taking a drug and begin behavior therapy at the same time and become more anxious, it will be unclear whether it is the drug or the behavior therapy that is triggering the anxiety. If you have been taking a drug that is reducing your OCD symptoms and you stop taking it while you are starting behavior therapy, relapse with drug withdrawal might make behavior therapy more difficult for you. As these examples illustrate, there can be some advantages to changing only one treatment at a time if you are considering changing your treatments. Are You Taking Non-SRI Medications? Many individuals with OCD take various medications such as antidepressants and anti-anxiety drugs. Anti-anxiety drugs (also called anxiolytics, such as Valium and Xanax ) may reduce general emotional discomfort, but they have not been found to reduce OCD symptoms. Non-SRI antidepressant medications are not helpful for OCD symptoms but can relieve depression that often accompanies OCD. If you are taking medication, it is important that you tell your therapist what you are taking, so that the therapist can communicate with your physician about coordinating your behavior therapy program with your drug treatment. What Benefits Will You Receive From Your Program? From the good results of many studies of exposure therapy for OCD, you can expect an excellent chance to improve. Experience has shown that, over several years, about 75% of clients who went through an intensive 16

25 1-month treatment program achieved substantial relief in that short period of time. More importantly, most of these retained their gains for at least 18 months afterwards. How can the good long-term improvements from behavior therapy be explained? One explanation for the good maintenance is that the treatment is essentially a learning program. When something is learned and rehearsed quite a bit, it becomes a strong habit, and you carry it with you wherever you go, even after you graduate from the program. Unfortunately, there is no guarantee that the program will be successful for you, but the odds are so good, it is a very worthwhile treatment to try. What does the improvement feel like? Successful graduates of the intensive exposure program feel little discomfort with the situations that bothered them before treatment. Because of this, they have far fewer temptations to avoid these situations and to do rituals to reduce their discomfort. Most clients are doing almost no rituals by the end of treatment and are no longer avoiding situations that they once feared. Obsessions are reduced, too, both in frequency and persistence, but they usually do linger for a while after the end of treatment. If you don t yield to the occasional urges to avoid or ritualize, the obsessions will be weakened even further over time. In addition to relief from OCD symptoms, there is relief from the life disruption that they cause. Individuals with OCD often spend much time and energy trying to manage or work around their symptoms. When the symptoms are relieved, the time you used to spend on obsessions and rituals is freed for more satisfying things. Also, when you stop avoiding feared situations, you will be able to expand your activities (such as going back to work, socializing, dating, participating in public cultural events, etc.). What Price Will You Pay? Good therapy always takes time, effort, and expense, and this program is especially challenging. First of all, if you do the intensive program, you must come to sessions frequently several times per week. Depending on your practical circumstances, this may be quite difficult. It could require that you make special arrangements at your job. You may have to arrange for transportation or childcare. Even if you pursue a nonintensive program with a therapist or a self-exposure program without therapist assistance, you must still set aside substantial time to practice daily. Besides taking the time for attending sessions, you will have to take time each day to do homework practice. Unless you devote all the time needed to homework practice, the treatment will not be successful. In addition to time and effort, the program requires that you tolerate the distress of doing challenging exposure practices without ritualizing. Remember, it is not simply the severity of your 17

26 OCD symptoms, nor their duration, nor your age, that determines whether the program will be helpful. Very important factors are your motivation to change yourself and how much you adhere strictly to the program. Now that you are familiar with the likely benefits and costs of the program, you are in a position to decide whether or not to participate. It comes down to weighing what the OCD costs you in both the short and the long run against the time, effort, money, and temporary distress you will experience during the 1 month of the program. Consider the program an investment in your future. One point to keep in mind is that you may already be expending as much day-to-day effort on your OCD as it would take to complete the program. If the potential benefits seem to outweigh the costs, then it makes sense to pursue treatment. Are you ready for this commitment? The answer to this depends on how confident you are about the program and how determined you are to reduce your OCD symptoms, even though you may be anxious about treatment. If you are not determined, then you are probably not ready to participate successfully in the program. If you do choose to do an exposure therapy program, you should be clear about your commitment and goals. You have not been able to rid yourself of the OCD on your own. Your way of coping with the obsessions, that is, with avoidance and rituals, has not worked very well. In fact, it has contributed to the trouble you are having because it is a great burden to be avoiding and ritualizing, and because avoiding and ritualizing strengthen, rather than weaken, the obsessions in the long run. Your goal is to eliminate the rituals and avoidance and to substantially reduce the frequency, persistence, and distress of the obsessions. You will develop a plan of effective exercises, and do the exercises correctly. The techniques are very powerful, but only if you use them correctly. Many people have achieved substantial relief from their OCD symptoms by participating in a program of exposure and by refraining from ritualizing. If you follow a good program and do the exercises with energy and diligence, you are likely to achieve what you want. If you reject the program and spend your energy second-guessing which exercises you need to do and don t need to do, refuse to do certain exercises, cheat on your homework, or simply don t do some or all of it, you very probably won t improve with this program. If you are not committed to trying as hard as you can to do the prescribed exercises, it would be better not to start the exercises, because the program probably won t work for you. There are two essential parts to an exposure program. You will systematically confront things that provoke your obsessions, even though this will be distressing for you. The distress that you experience is an important indicator 18

27 that you are doing useful exercises. If you do not experience any distress when you first do an exposure exercise, something is wrong with either the exercise or the way you are doing it. You will develop a list of situations that you will confront for your therapy. You will start with situations that you rate as moderately difficult, and progress to the most difficult situations on the list on a predetermined day. You will stay in each situation until your distress decreases noticeably, and you can count on that happening. As you repeatedly confront that situation day after day, it will bother you less, until eventually it hardly bothers you at all. As you start to get used to each situation on the list, you will add a new situation to confront while continuing to practice exposure to the situations that you have already done. Each day for homework outside of the session, you will practice the exposure exercises that you have done in the session. The homework can take up to several hours each day throughout the program. You will still do the exposure homework whether you meet with a therapist on a particular day or not. There are to be no days off on which you may choose to return to the old habits of avoidance and ritualizing. The second essential part of your program is stopping the rituals. This means that you commit yourself to stop all rituals completely on the first day of the program. Unlike the gradual way that you will do the exposure exercises, you will try as hard as you can to stop your rituals all at once, cold turkey so to speak. This means that you will try to stop your main rituals as well as any minor rituals. Continuing to ritualize will undermine the effects of the exposure exercises, so that the distress you experience during the exposures will be for nothing. There s little point in doing an exposure exercise if you undo it afterward by ritualizing. You must try to resist even strong urges to ritualize. If you are afraid of giving in, you must contact your therapist or a supportive person before you carry out a compulsive act, so that you can get some support to resist the urges. Occasionally, people make mistakes and find that they engaged in a ritual without thinking about it because it is such an automatic habit. If your habit of ritualizing is so strong that you cannot resist, you should immediately record what happened on the Self-Monitoring of Rituals form so that you can develop ways to help yourself better resist the urge. Do not wait to record this instance until the end of the day or until just before coming to the session, because you may not remember exactly what happened. After recording the ritual on your selfmonitoring form, you should re-expose yourself immediately to the situation or thought which provoked the rituals, but without ritualizing. During your program, in order to maximize the effects of exposure, you may have to refrain from some things other people normally do (such as washing or checking). For instance, many people do take a shower every day, but if you shower excessively, you should not shower daily. This is because refraining 19

28 from actions associated with your OCD is a powerful way to weaken your OCD patterns. It is important during the treatment period that someone (therapist, family members, friends) will be available to offer emotional support. Two key elements in being supportive are (a) not collaborating in your avoidance and rituals, and (b) minimizing interpersonal conflicts with you during the treatment period. 20

29 Chapter 2 Identifying Your Obsessions and Compulsions Now that you are familiar with the major types of obsessions and compulsions, you can identify the particular areas that are troubling you. The following list can help you do this. Specific Areas of Obsession and Compulsion Washing and Cleaning Avoid touching certain things because of possible contamination Difficulty picking up items that have dropped on the floor Clean household excessively Wash hands excessively Take extremely long showers or baths Overly concerned with germs and disease Checking and Repeating Check repeatedly that something has been done correctly, or that its condition is satisfactory Difficulty finishing things because I repeat actions Repeat actions in order to prevent something bad from happening Excessive concern about making mistakes Excessive concern that someone will be harmed because of me Certain thoughts that come into my mind make me do things over and over again 21

30 Ordering Must have certain things set in a specific order Spend much time making sure that things are in the right place Notice immediately when my things are out of place Important that my bed is straightened out impeccably Need to arrange certain things in special patterns Become extremely upset when things are rearranged by others Hoarding Difficulty making decisions about discarding items Bring home seemingly useless materials Home has become cluttered with collections Do not like other people to touch my possessions Find myself unable to get rid of things Other people think my collections are useless Thinking Rituals Mentally repeat certain words or numbers Review certain things to myself to feel safe Spend a lot of time praying in a special way that is not a customary religious practice Bad thoughts force me to think about good thoughts Make mental lists to prevent unpleasant consequences Stay calm at times by thinking the right things Pure Obsessions Just have upsetting thoughts that come to mind against my will Little control over upsetting thoughts In the past month, how much time have you spent, on an average day, engaged in these symptoms? Write the number of hours and minutes in the space provided in Exercise

31 Exercise 2.1. Time Spent on Obsessions and Rituals Ritual Time Spent (hrs/mins) Washing and Cleaning Checking and Repeating Ordering Hoarding Thinking Rituals Other Obsessions and Rituals Total Time After you have identified your obsessions and compulsions in general and how much time you engage in them, the next step is to evaluate your symptoms in more detail in order to prepare yourself for the treatment program. Begin with analyzing your obsessions. Obsessions It is useful to consider three factors that are involved in obsessions. The first is the situations or objects that trigger the obsession. The second is the thoughts, images, or impulses that come to mind and bring on distress, including any ideas of anticipated disastrous consequences if one doesn t protect oneself or other people by performing rituals, such as washing, avoiding certain situations, or somehow trying to resist the obsession. The third is the kind of distress that the person feels as part of the obsession. It could be anxiety, disgust, guilt, or a combination of emotions. Some examples of situations or objects that trigger an obsession are given here. A person who engages in washing rituals may become distressed after touching a public telephone, handling household chemicals such as insecticide, or touching shoes. A person who has checking rituals may get upset after hitting a bump while driving to work, or when putting in an envelope a check the individual had written to pay a bill. A person who hoards might become distressed when forced to throw away last year s newspaper. 23

32 Now, think about your own particular obsessions. Use the form in Exercise 2.2 to list about 15 situations or objects that cause you the most distress and trigger a strong urge to ritualize. Write in both the situation and a rating of how much distress you feel when you confront it. You can use a scale called Subjective Units of Distress (SUDs) which ranges from 0 to 100; 0 indicates that being in the situation or touching the object does not bother you at all; 100 means that the situation is the most distressing that you can imagine and would trigger extreme distress for you. On this scale, rate each situation somewhere between 0 and 100. Situations that trigger mild distress can be rated as low as 10 or 20 SUDs. If you think that you would be moderately distressed about the situation, you would rate it somewhere around 50. If you think you would be highly distressed, rate it between 50 and 100. Try to include in your list at least 10 situations rated 50 or higher. Exercise 2.2. List of Situations That Trigger Distress, Avoidance, or Rituals Distressing Situation/Object Degree of Distress (0 100 Subjective Units of Distress)* * 0 SUDs = no distress; 100 SUDs = highest possible distress 24

33 If you do not leave the house without repeatedly checking the light switches, rate how distressed you would be if you left without checking at all. If you think that this would be moderately difficult for you, rate it at around 50. If you check repeatedly that the stove is turned off when you are about to leave the kitchen, rate how distressed you would be if you left without checking at all. If this situation is the most distressing you could imagine, put it at the top of your list and rate it highly, near 100 SUDs. It is not absolutely necessary to fill in all 15 spaces, but it is important to include all the main situations that bother you. Consider any thoughts, images, or impulses that trigger your distress. An example of this is the idea that you might jump or drive off a bridge. This idea might occur whether you are actually on a bridge or not. Another example of a distressing idea is I could stab my child, and I m afraid that I will. Clearly identifying obsessive thoughts can be difficult, so be patient and try to recall what obsessions you ve had most frequently in the last week. Use the form in Exercise 2.2 to list these obsessions and rate how distressing they are on the scale. Some people have difficulty identifying particular situations or objects that trigger their obsessions. Sometimes an obsession may be triggered by an identifiable thought, and sometimes the obsessions seem to occur spontaneously, without any identified trigger. If you can t identify any situations or thoughts that provoke obsessions, skip the exercise above and go on to the next one. Anticipated disasters can also be part of the disturbing content of obsessions. For example, if you are concerned with contaminants, and you encounter them or do not clean them off, you might be concerned that you will get sick or cause others to get sick. The obsession could be about a specific disease (such as syphilis) or about no particular disease. If you check appliances, you may be concerned that you might cause a fire or explosion. If you hoard, you might worry that, if you discard an item, it could be something important for current or later use. Some individuals cannot identify a particular anticipated disaster. Instead, they are concerned that something bad will happen, but it is unclear just what it would be. Other people who can t identify a particular anticipated harm anticipate that they will be extremely distressed unless they avoid or ritualize. Think about whether you anticipate that some harm will occur if you do not avoid or ritualize. On the form in Exercise 2.3, list anticipated consequences that trigger distress in the range of 50 to 100 SUDs. 25

34 Exercise 2.3. Anticipated Consequences of Not Avoiding or Ritualizing Anticipated Harm Distress Rating ( SUDs)* * 50 SUDs = moderate distress; 100 SUDs = highest possible distress Individuals with OCD often try to avoid certain objects, situations, thoughts, or activities that trigger obsessions and distress. A person who carries out washing rituals because of concern about germs might avoid sitting on toilet seats, especially in public bathrooms, or perhaps avoid public bathrooms altogether. Individuals who hoard might avoid discarding items because they could lose something important. A person concerned about running over pedestrians might avoid driving at night or in crowded areas, or might avoid driving completely. Think about the situations you avoid to minimize obsessions and distress, and list them on the form in Exercise 2.4. Indicate how often you avoid each item. Exercise 2.4. List of Situations You Avoid Situation Distress (0 100 SUDs)* How Often Do You Avoid It?

35 Situation Distress (0 100 SUDs)* How Often Do You Avoid It? * 0 SUDs = no distress; 100 SUDs = highest possible distress Next, consider what rituals (i.e., compulsions) you are doing to reduce distress or prevent harm. The following Exercise contains a list of mental and behavioral rituals. Mark each of the rituals that applies to you, estimate how much time you spend on it per day, then rank each ritual on how big a problem it is for you. Place a 1 next to the ritual you do most frequently, a 2 next to your second-mostfrequent ritual, and so forth. Exercise 2.5. Rituals Ritual Rank Time Spent Washing and Cleaning Checking Repeating actions Ordering objects Hoarding Praying Special thoughts Good numbers Mental listing Reviewing past events Other (describe: ) 27

36 Distinguishing Obsessions and Compulsions From Other Psychological Problems Before you decide whether to use the program described in this workbook, it is important to consider whether you do your rituals to reduce your obsessions and related distress. This program is designed for people who realize that their obsessions are exaggerated and unwanted and whose rituals and avoidance are intended to decrease their obsessional distress. If you do not experience your obsessions, rituals, and avoidance in this way, this may not be a helpful program for you and you should probably consult a specialist in OCD for further evaluation. For example, if you repeatedly say words, make sounds, or perform actions automatically without knowing why, these actions may be tics rather than compulsive rituals. Repeated, rigid sequences of actions also characterize other mental disorders. Individuals with schizophrenia, for example, sometimes repeat actions, such as moving their hands in a certain way. People with brain damage or mental retardation may also show stereotyped behaviors. The rituals of OCD are different from those other repeated actions in that OCD rituals are intended to neutralize particular obsessions, to reduce obsessional distress, or to prevent harm. In other words, only people with OCD will connect the obsessions and compulsions. Sometimes habits such as overeating, nail biting, or pulling out hairs from the head are thought to be like OCD and part of an OCD spectrum. However, these habits are unlike the ritualistic behaviors of OCD in that while these behaviors may reduce general tension, they are not intended to reduce a specific obsessional distress. Moreover, people who engage in these habits do not anticipate disasters if they do not overeat, bite nails, or pull hairs. Another problem that resembles OCD is obsessive-compulsive personality disorder (OCPD). Persons with this disorder are so preoccupied with being perfect, orderly, and in control that they often lose sight of practical goals. On the surface, these characteristics resemble some of the symptoms of OCD. However, people with OCPD do not get stuck doing rituals to prevent disasters. Furthermore, they typically think that their perfectionistic and controlling style is a good way to live. Some people with OCD also have obsessive-compulsive personality, but others do not. Not every overly perfectionistic person has OCD, and not everyone with OCD is neat and orderly. In summary, many people with OCD can recognize that their obsessions and compulsions are unrealistic or excessive, but a minority do not. Because the majority of individuals with OCD recognize the senselessness of their obsessions and rituals, they often try with difficulty to resist them. They also recognize that their obsessions and urges to ritualize have not somehow been put there by someone else. 28

37 People with OCD are often depressed. In many instances the depression is a result of a reaction to the OCD symptoms, and the depressed mood usually lifts after successful treatment for the OCD symptoms. In other instances, ruminations are part of the depression. Depressed people typically ruminate about being unworthy and about the world around them being unpleasant or hostile. Their ruminations tend to reflect general themes such as I m unworthy, I ll never get better, and No one likes me. The ruminations of depression differ from obsessions of OCD in two ways. First, they are not temporarily relieved by rituals, and second, they are not focused just on anticipated disasters but past, present, and future sad conditions. If you are depressed and experience depressive ruminations as described above but you do not ritualize, the program outlined in this manual is unlikely to help you. It has been found helpful for the obsessions of OCD but not for depressive ruminations. Therefore, you will want to consult a mental-health professional who will evaluate your depression and direct you to an appropriate treatment. Should You Seek Professional Help? Once you have evaluated your symptoms and understand the nature and severity of your OCD problem, you can decide whether you wish to use the workbook and follow the program on your own or seek the guidance of a therapist. There are no fixed rules that can tell you what to do, but the following guidelines may be helpful. In order to make an informed decision, you can review your answers to the questions you answered earlier in this chapter. Did you rate several items about 90 or about 100? Now, refer to your answers and total the hours you spend each day on your rituals. If your obsessional distress is extreme and you also spend much time on obsessing and ritualizing (2 or more hours per day), your OCD symptoms are probably severe enough that you will profit from the guidance of a mental-health professional who specializes in OCD. This is because severe symptoms are more difficult to overcome on your own. The expert will further evaluate you and help you develop and follow the appropriate cognitive-behavior program. 29

38

39 Chapter 3 Understanding Cognitive-Behavior Therapy for OCD What is Cognitive-Behavior Therapy for OCD? The cognitive-behavior treatment described in this workbook is called exposure and ritual prevention. It is designed to weaken two types of habits. The first is the habit of feeling distressed around the particular objects, situations, or thoughts that bother you. The second habit to weaken is doing rituals when you feel distressed about the things that bother you. In other words, the program is designed to help you stop being distressed and to stop ritualizing. This program includes three components: actual exposure, imaginal exposure (also called imagery practice), and ritual prevention (see the following chart). The Components of Treatment for OCD Exposure: Staying for long periods in the presence of a feared object or situation that evokes anxiety and distress (e.g., actual contact with contaminants) Imagery Practice: Mentally visualizing oneself in the feared situations or visualizing their consequences (e.g., driving on the road and hitting a pedestrian) Ritual Prevention: Refraining from ritualistic behavior (e.g., leaving the kitchen without checking the stove, or touching the floor without washing one s hands) What Is Exposure? During actual exposure, you confront the situations that provoke obsessional distress. After enough exposures, your anxiety decreases. This is called habituation. If this is true, you might wonder why you haven t relieved your 31

40 distress already, because you have had many encounters with situations that provoked obsessions. The reason is that simply provoking an obsession is not enough. It must be done for a long enough time for the distress to diminish on its own, and it must be done that way repeatedly. For example, a person who washes too much often touches contaminated things but then washes to get rid of the contamination and to try to feel better. Hand washing afterwards makes the exposure too short to promote habituation. Because many people with OCD hold to mistaken beliefs that anxiety remains forever unless they escape or ritualize, short exposures cannot disconfirm this mistake. Another error is the idea that something terrible will happen if you don t ritualize. Again, only prolonged exposure without ritualizing can put this mistaken belief to a test and disconfirm it. In this program, therefore, you will refrain from the ritual that you usually do until the distress and the urge to do the ritual decrease. This is called ritual prevention. If exposure to situations that trigger obsessional distress and urges to ritualize is necessary to relieve OCD, how can you improve without actually confronting your anticipated harm? You can confront the harm by visualizing it in your mind. In imaginal exposure, you create in your mind detailed pictures of the disaster that you fear will occur if you do not avoid or ritualize. As in actual exposure, the obsessional distress gradually decreases during imaginal exposure. Imaginal exposure is also helpful for individuals in whom obsessions occur spontaneously and are not triggered by any identifiable situations. For example, a person might have a blasphemous thought at any time or place, which is the main source of obsessional distress. In this case, there is no particular situation for the person to confront, and therefore the person can t practice remaining in an exposure situation for prolonged periods. In using imaginal exposure, the person would purposely imagine the blasphemy repeatedly, without trying to eliminate or neutralize it with a prayer or other ritual. Imaginal exposure may also be especially useful when a person is very distressed about disastrous consequences that she fears will occur. For example, if a person fears that her home will burn, she would not burn her house as an exposure exercise. However, she can for a prolonged period imagine her house burning, until her distress decreases. Similarly, someone who fears that he has run over a person who is now lying in the road would not purposely injure someone. In imaginal exposure, you create a mental image of the disaster that you fear will occur if you don t ritualize. As with actual exposure, distress gradually decreases during this imagery. Another reason for using imagery is to make subsequent actual exposure easier for you. If you are extremely distressed about the idea of confronting a situation or object that provokes your obsession, you might find it helpful to imagine confronting it. The decrease in your distress during imagery will carry over to the actual exposure. 32

41 What Is Ritual Prevention? As explained earlier, when someone with OCD encounters feared situations or obsessional thoughts, this triggers distress and urges to ritualize in order to reduce the distress. Deliberate exposure can cause the same distress and urge to ritualize. Yielding to the temptation to reduce distress through ritualizing strengthens the OCD pattern in the long run, despite any short-term relief. It also does not allow individuals with OCD to realize that the harm they fear will happen does not really happen even if they do not protect themselves or others by ritualizing. In addition, the rituals do not permit the person to realize that anxiety does not remain forever; rather, if you continue to stay in the fear-evoking situation, anxiety and distress will diminish gradually. Therefore, it is essential to abstain from rituals, even when you have strong urges. Accordingly, in this treatment program, ritual prevention is practiced to weaken the habit of ritualizing. Why Should You Do Exposure Therapy and Ritual Prevention? Perhaps you are asking yourself: Why should I suffer the distress of confronting feared situations on purpose without doing some rituals to obtain relief? Remember, this program is designed to weaken two types of connections. The first is the connection between distress and the objects, situations, or thoughts that trigger it. The second connection is between ritualizing and relief from obsessional distress. In other words, after you carry out your rituals, you temporarily feel less distress, so you continue to engage in this behavior frequently. This program is designed to help you change these patterns. In addition to weakening connections, the program is designed to help correct mistaken ideas that are common in OCD and that cause considerable distress. These ideas are: (a) the rituals prevent harm from happening to myself or others; (b) I have to avoid the distressing situation because if I do not avoid it, distress will continue forever and even will worsen; and (c) if I don t avoid or ritualize, the anxiety will get worse and I shall fall apart or go crazy. The first idea common in OCD is that it is necessary to avoid or ritualize to prevent harm. Most people can think of potential disasters that might happen to them or to others if they carry on necessary daily activities such as driving a car. However, because they can think about the risk without intense, disabling distress, they are able to see that the actual risk is so low, it should be ignored. But many people with OCD become overwhelmed with distress when thinking about certain potential disasters that might happen to them or that they may inflict on others. For example, individuals with OCD might become intensely anxious about the thought of their house catching fire, being possessed by the devil, or contracting AIDS. The intense feeling prevents them from 33

42 making rational judgments about how risky a situation is and what they do to protect themselves or others. To be on the safe side, the person with OCD will avoid or ritualize to prevent even the most remote possibility of harm. Consequently, the individual does not have the opportunity to learn that the feared situation is actually quite safe. The person who carries out checking rituals thinks that my house didn t catch fire, either because I never use the stove or because I am always extremely careful to check it. The person who engages in washing rituals thinks, Yes, I did not get sick after my visit to the hospital because I washed my hands with Lysol and scrubbed myself in the shower. This kind of thinking perpetuates avoidance and rituals. Exposure works against this type of mistaken idea. When you actually confront a mistakenly feared situation again and again and don t ritualize, you realize that no harm follows. Thus, you recognize that the risk is remote and learn to ignore it. For example, Michael was afraid that his house would catch fire, so he refused to use his central heating, even in cold weather. For therapy, he had to start the heater and leave it on while he was away from home. After 24 hours, the house was comfortably warm inside but did not catch fire, and Michael learned that his fear was unfounded. Mindy was concerned about getting poisonous household chemicals into food that her family would eat. Therefore she never cooked for them, nor did she ever use household chemicals. In addition, before entering the kitchen at any time, Mindy washed her hands extensively, so that any dishes or glasses she used would not be inadvertently poisoned. For her therapy, Mindy placed a bottle of oven cleaner on the counter, then prepared and served food to her family without first washing her hands. Her family enjoyed the food and didn t die from it, and Mindy learned that her fear was groundless. The second mistaken idea people with OCD tend to have is the belief that they must avoid the distressing situation, or else they will be distressed forever. This leads them to avoid many situations or to ritualize if they cannot avoid them. However, during prolonged exposure, intense anxiety gradually decreases ( habituation ). If someone confronts a distressing situation for a prolonged period (e.g., 1 2 hours), the individual will experience a gradual decrease in distress until the distress is gone. As the distress drops, it becomes easier to think clearly about whether the situation is actually dangerous. Later on, if the same or similar situation arises, there will be some distress, but much less than previously. Because most people tolerate stressful situations for prolonged periods for practical reasons, they have learned that the distress does not persist forever. This program is designed to help you remain in the distressful situations so that you too will realize that the distress decreases with time. 34

43 A third common belief in OCD is that if I don t avoid or ritualize, the distress will get so bad that I ll lose control of my mind. For example, Rennie was concerned that if things were not arranged neatly and in the right order, she would be so uncomfortable that she would not be able to stand it, and she would lose her mind and be committed to a psychiatric hospital. For her therapy, Rennie disordered her office and bedroom and did not put them back in order even though she became very uncomfortable. Her discomfort eventually decreased, and she did not lose her mind. She learned that anxiety did not persist forever and did not produce insanity. A program that involves prolonged actual exposure is designed to help you, whether you are afraid of contracting a disease from public bathrooms, causing automobile accidents, discarding something important, or injuring someone with a knife. Naturally, when you first confront a feared situation, you will be distressed. However, if you remain long enough in the situation, and do so repeatedly, the distress will diminish. This experience changes your idea that the distress will last forever and perhaps lead to insanity, because you learn that if you wait it out, the distress decreases. You might be wondering how it can help you to imagine that the disaster you dread actually does occur if you refrain from avoiding or ritualizing. Such imagery helps because when you repeatedly imagine the harm happening, you become less distressed while you are thinking of the harm, and you can evaluate the danger more realistically. You also learn that anxiety does not last forever because the distress decreases during prolonged imaginal exposure. Emotional Involvement During Exposure Exercises For actual or imaginal exposure exercises to be helpful, you must become emotionally involved during the exposure. Specifically, the exposure situation must evoke the same kind of obsessional distress that you experience when obsessions occur in your daily life. To promote emotional involvement, you must develop exposure exercises that are a good match to the real-life situations that provoke your obsessions and urges to ritualize. If you are mainly distressed by contamination related to cancer, and for your exposure exercise you visit a hospital that has no cancer ward, the exercise will be unhelpful because the exposure situation does not match your obsessional concerns. Thus, it will be hard for you to become emotionally involved when your exercises are unmatched to your obsessions. Even if you develop an exposure exercise that is very well matched to your obsession, you must approach it in a way that involves you emotionally. This means that you must pay attention to the distressing aspects of the exposure situation, rather than try to ignore them or pretend that they are not there. 35

44 36 This is true for both actual and imaginal exposure exercises. For example, if you pretend that the cancer ward is a cardiac unit in order to reduce your distress, the exercise will be less effective. Therefore, during your exposure exercise, you should think about the potential harm that concerns you. For example, if you are afraid of using public bathrooms and you go to a public toilet as an exposure exercise, while you are there you should think about what concerns you about the toilet, such as getting a venereal disease. In the same way, during imagery practice, you should include anticipated disasters and work at imagining them as vividly as you can.

45 Chapter 4 Designing Your Program The first thing you need to decide is how long your program should take and how intensive it should be. The program described in this workbook is flexible, and you can schedule its length according to your unique circumstances. If your symptoms are relatively severe, the recommendation is that you do the program intensively and work hard daily to complete a full schedule of exposure exercises within a 1-month period. If your symptoms are relatively mild, it may be sufficient to devote only a few hours per week for up to 2 or 3 months, until you have conquered your main obsessions and compulsions. To decide whether your OCD is mild or severe, you can refer to the analysis of your symptoms that you completed in Chapter 3. If your obsessions and rituals occupy more than 2 hours per day, then you probably need an intensive, daily program. Otherwise, you should adjust your program according to how much progress you make each week. Beginning Your Program This chapter describes in detail an intensive 3-week self-exposure and ritual prevention program. You can try to follow this intensive program, or you can choose to go at a slower pace. But it is important that you do some homework every day. To set up your schedule, you need to plan the three important parts of your selfhelp program: imagined exposure, actual exposure, and giving up your rituals. Once you have planned what your exercises will be, you can get on with actually doing them. Setting Up Your Imaginal Exposure Exercises Review Exercises , in which you made up lists of troublesome situations, your thoughts and feelings about them, and the bad consequences you feared 37

46 would occur if you did not avoid or ritualize. From these lists, you will identify your most troublesome situation and make up a brief story. This story is called an imagery script, because you will use it to help yourself imagine being in that situation. Before you make up your imagery script, read the sample story given here to get an idea of how your story should read. Sample Imagery Script You need to drive to the market, but you don t want to because it is the middle of the afternoon and children are getting out of school about this time. The way to the market passes a school, and you are worried that you might hit a child with your car. You really have to get to the market, so you go out to your car, get in, and start the engine. It is a cloudy day, and a light rain is falling. You turn on the windshield wipers and they sweep back and forth, making a soft swish. You sit in the car, thinking that you don t want to drive past the school. Your heart races as you feel the engine vibrating the car a little, because you know how big and powerful a car is compared to a small child. Then you remember that you have to get to the market. You hear a clink when you put the car in gear and press harder on the brake pedal. You release the brake and the car moves forward. You turn onto the street that goes past the school to the market. You can see the brown brick school ahead, and there are some children walking on the sidewalk. There is a crossing guard in a blue and white uniform standing by a traffic light, preventing some children from running out into the street. You get closer to the school, and there are groups of children running along the sidewalk. Sometimes a child jumps into the street without looking for traffic. As you drive past a large group of children, you feel a bump and hear a shout. You tense up immediately. You don t see a child against your car, but you think that you must have hit someone. You break out in a sweat when you think that a child could be crushed under your car. You have heard of people being dragged underneath moving cars, and you know that a child is small enough to fall under your car without your seeing it happen. You hear a siren and see flashing lights and think that it must be an ambulance coming for the injured child. You see more children running in the direction where you just were and think that they must be going to see the accident. You feel that you must have done something terrible. This is just an example, so your story does not have to be exactly like this. It may be easier for you to write this story if you imagine yourself actually being in the distressing situation. Imagine you are in the situation and that you decide not to ritualize. Now write your story about what terrible events will occur next. Your story should be long enough that it takes 3 minutes to read aloud. Once you have written it, you will record it on a 3-minute audio cassette loop tape, of the kind 38

47 used for outgoing messages on answering machines. Loop tapes play the same material continuously without rewinding and can be purchased at office supply stores and audio equipment stores. You should purchase three or four loop tapes. They come in different lengths, so be sure that you buy the 3-minute type. Never try to rewind these tapes; this can destroy them. A good way to write your story is: 1. Pick a situation from the list that you made. 2. Use the lists of thoughts, images, impulses, and feared consequences to remind yourself of what would go through your mind if you were in the situation. 3. Think of yourself in the situation and just write down what would be happening: a. what the situation is b. what you are doing c. what you are thinking and feeling d. what other people are doing e. what bad consequences are happening and how you are reacting to them Now, follow steps 1 3 and write down an imagery script. Next, review the imagery script that you created and make sure that it matches the obsessions that you have during that situation. Before you record the story, use a clock with a second hand to time your reading. If it is a little more than 3 minutes, you can read it a little faster or shorten the story. If the story takes less than 3 minutes to read, you can read it a little more slowly or add something to the story. When you can read your story in 3 minutes, record it onto the 3-minute audio cassette loop tape. Then, play it back so you can hear that it was recorded properly. The tape does not have to be perfectly recorded. If you make a mistake or stumble over a word during the recording, just keep going. If you have recorded the script properly, it should play through once completely and then repeat itself. Repeat this process with the most troublesome two or three other situations, thoughts, and images that you have listed in Exercises As you go along in your program, you can make as many stories as you need to address your different obsessional fears, but to get started, just make up stories for the three or four most troublesome situations. To remind yourself of a good way to make up a script, review the suggestions listed earlier about how to do this. Use separate tapes to do 3-minute recordings for each of the obsessional scripts you have made. Label the tapes to identify which situation is described. You will use these tapes during your imagery practice to help you imagine being 39

48 in the situations. The tape-recorded script will remind you of the details of the feared situation or thought and help you to keep your mind on the image for an extended period. Planning Your Imaginal Exposure Exercises When you are ready to begin imagery exercises, here are the guidelines to follow. 1. Find a tape recorder. It is practical to use a portable tape player with an earphone so that you can be flexible about the place you choose for this exercise. 2. Review the loop tapes you have prepared. 3. Begin with the least distressing of the tapes. 4. Start the tape, then close your eyes and listen to the story on the tape. Imagine that it is actually happening now. Keep your eyes closed throughout the exercise. 5. Keep imagining at least until your distress decreases noticeably. 6. Use the Imagery Practice Record to monitor each imaginal exercise. (You may photocopy this form as needed.) Write down the title of the story that you practiced that day and monitor your highest and lowest distress levels. 7. Once your distress about a certain story remains low for several practices, you can stop practicing it. 8. Continue your imagery exercises until you have successfully dealt with all the stories that you have prepared. 40

49 Imagery Practice Record Date Begin Time End Time Image Script Initial Distress Level (0 100 SUDs)* At end of session, rate how uncomfortable you felt: During the first 5 minutes When you were most uncomfortable At the end *0 = no distress; 100 = highest possible distress Describe below your experience during the practice and any difficulties you encountered: Copyright 1997 by Graywind Publications Incorporated. All rights reserved. 41

50 Planning Your Actual Exposure Exercises Review the list of distressing situations that you compiled in Exercise 2.2. Use this list, along with the imagery scripts that you have made, to organize your schedule of exposure exercises. Use the following guidelines in planning your exposure tasks: 1. Begin with situations that provoke moderate distress, about 40 to 50 SUDs. 2. For each practice period, stay in the situation until the discomfort decreases noticeably. Remember, relieving distress by getting away from the situation strengthens your OCD problems rather then helping you control them. 3. Practice daily, allowing at least an hour at a time. Continuous, long exposure is effective; interrupted, short exposure is not helpful. 4. Remember, if distress does not decrease during an exposure period, repeat the same practice again the next time for a longer period. 5. Focus on the details of the situation during exposure exercise. Remember, trying to relieve distress during exposure by pretending to be doing something else will limit the effectiveness of the practice. 6. Use the following Actual Exposure Practice Record to monitor each exposure exercise. (You may photocopy this form as needed.) Write down the situation, object, or image you practiced that day, and monitor your distress level periodically. 7. Once your distress about a certain situation or thought remains low over several days, you need not practice it regularly. 8. Continue your exposure exercises until you have successfully dealt with the most distressing situations or images on your list. If you do not confront the situations that evoke the highest distress, you are likely to lose some of the gains that you made during the program. 42

51 Actual Exposure Practice Record Date Begin Time End Time Exposure Situation During the practice session, rate your discomfort (0 100 SUDs)* Beginning 10 min 20 min 30 min 40 min 50 min 60 min 70 min 80 min 90 min 100 min 110 min 120 min *0 = no distress; 100 = highest possible distress Describe below your experience during the practice and any difficulties you encountered: Copyright 1997 by Graywind Publications Incorporated. All rights reserved. 43

52 Planning to Stop Your Rituals The first step in planning to stop your rituals is to review the list of your rituals in Exercise 2.5. Ideally you should stop all the rituals from the start of your program, but first you should pay attention to when and how you ritualize and keep a record of your ritualizing activities. How to Monitor Your Rituals Ritual monitoring has two purposes. It increases your awareness about rituals, and it gives you an accurate picture of them. Monitoring is especially helpful if you are doing your rituals automatically or not paying much attention to them. (Obviously, it is very difficult to stop rituals of which you are unaware.) People generally find self-monitoring burdensome, but it is an extremely important technique for controlling your rituals. Self-monitoring of your behaviors is a powerful treatment procedure in itself and has actually been found to help people exercise self-control, probably because it helps them to be very aware of what they are trying to control. Another benefit of the selfmonitoring is that your therapist can use it to monitor your progress and adjust the treatment exercises accordingly. It can be difficult to monitor your compulsions, especially if you have very many of them or if you are not used to paying attention to when they occur. The Self-Monitoring of Rituals forms will make it easier for you to record your compulsions. (See Figure 4.1 for an example of how to record your rituals on the Self-Monitoring of Rituals form. These forms are available from The Psychological Corporation.) When you record your compulsions, remember the following: Do not guess the time you spend ritualizing. Use a watch to determine the actual time. Note the time before you start the ritual, then note the time again when you stop the ritual. Keep the monitoring form with you during all waking hours. As soon as you notice that you are ritualizing, stop the ritual, look at your watch, and write the time. Then, if you continue to ritualize, pay attention to the time you stop, and write it on the form. Later on, when you start the exposure and ritual prevention program, use the self-monitoring form each day to record slips. Write down in a few words the trigger for ritualizing. The trigger could be a thought, an action, or a situation you encounter. Do not write long paragraphs on each of the triggers for the ritual. It is very important not to put off your recording until the end of the day or the beginning of the next day. Monitoring in this way will not be of much benefit to you and is probably a waste of time and effort. 44

53 Figure

54 At the end of each day, it is good to inspect your self-monitoring form from that day in order to evaluate your progress and to be aware of the remaining difficulties. The inspection of the form is also helpful in alerting you to whether or not you are using the form correctly. For example, if you recall that you washed several times but your form for that day is blank, you will be reminded that you did not monitor your rituals accurately. If you are working on your OCD problem with a therapist, it is important to share the daily monitoring forms with the therapist and discuss progress and difficulties that came up. Sample Guidelines for Stopping Rituals The following are some sample rules that clients have found helpful to guide them in stopping their rituals. Because there are so many different individual patterns of ritualizing, no single set of rules will fit everyone s situation. Examples are described here for washing/cleaning and checking, because these rituals are quite common. Guidelines for Refraining From Washing/Cleaning Rituals During the ritual prevention period, restrict the use of water on the body (i.e., no hand washing, rinsing, wet towels, or wash cloths are permitted). The use of creams and other toiletry articles (bath powder, deodorant, etc.) is permitted except when you feel they decontaminate. Shaving is done by electric shaver. You can drink water or use it to brush your teeth, being careful not to get it on your face or hands. Time-limited showers are permitted every 3 days for 10 minutes each, including hair washing. One way to do this is to take into the shower a wind-up kitchen timer that rings when the time runs out. It may be helpful to have a supervisor help you by monitoring the time of the shower and reminding you to stop when the 10 minutes are over. Spending extra time or care with specific areas of the body (e.g., genitals, hair) is prohibited. Guidelines for Refraining From Checking Rituals Beginning with the first session of exposure and response prevention, try to stop all extra checking. Do not automatically check everything that you do, even though that is what you are accustomed to doing (e.g., it is OK to lock the door but not to check it; it is OK to drop a letter into the mail box, but not to check the slot in any way to see whether the letter has gotten stuck). Only limited normal checking is permitted (e.g., it is OK to look in the rear-view mirror before changing lanes, but it is not OK to check the mirror whenever you get an obsessive intrusion about having caused an accident). At home, you can solicit the support of previously designated relatives or friends who have agreed to help you refrain from rituals. The support person should be available at your request when an urge to check is difficult to resist. They can assist by (a) refusing to help you check or to give you ritualistic assurances 46

55 of safety, (b) reminding you that it is very important for your relief from OCD that you resist the urge to check, and (c) staying with you until the urge decreases to a manageable level. Setting Aside Time for Your Program It will be important for you to organize in advance how you are going to set aside time for your program. Also, it will be important to inform selected family and/or friends about your program and how they can be helpful with it. Scheduling Time for Your Program If you choose to do an intensive program, it will require substantial time over a 3- to 4-week period, and you will need to set aside time each day for it. This will probably mean that there are some things you usually do that you will put aside during the month of your program. If you are employed full-time or responsible for taking care of young children, you may want to consider taking vacation time or finding help with child care. Otherwise, these important practical activities could interfere with the implementation of your treatment program. If you are choosing to do a less intensive program, you still must set aside time in your schedule for exposure exercises. Once you decide on how quickly you want to progress through the program, you must schedule enough time each day or week to reach your goals. You should write down your schedule of when and how long you will spend on your exposure exercises, then follow it rigorously during your program. If you don t make a schedule and follow it, day-to-day activities will take priority and you will not reach your goals. Informing Family and/or Friends One common way that family and friends react to OCD is to adopt the avoidances and rituals of the individual with OCD. For example, an individual who is concerned with contamination may insist that the spouse and children change their clothes in the basement upon entering the house, or refuse to allow the children s friends to enter the house because they are not participants in the pattern of avoidance and rituals. There are also other ways people involve others in their OCD. Perhaps you repeatedly ask others to assure you that a situation is safe or that you have ritualized enough. If your family or friends reassure you about these things, it probably worsens the OCD in the long run, even though you might feel better in the short run. If your family or friends are involved in your ritualizing or avoidance, it will be important to prepare them for your program by asking them to stop this 47

56 behavior and to explain to them what you are trying to achieve. However, you need to remember that it may be difficult for some friends or family members to stop what they have been doing, especially if they want to protect you from getting upset. Years of giving in to your requests to avoid or ritualize may have established habits that are difficult for them to get rid of! Therefore, you may have to remind your significant others that they should refuse to give you ritualistic assurances about safety, and to refuse to avoid or ritualize for you. For example, if your spouse has grown accustomed to entering the home through the basement and immediately removing clothes and showering for your sake, you may need to ask that the person enter through the front door and put clothes on the couch. Similarly, family members may find themselves continuing to perform a variety of household activities that they have come to regard as their responsibility because of your wishes to avoid feared situations. You will have to ask them to let you take on the responsibilities that you have avoided because of your OCD. Your program cannot succeed without the cooperation of family members in changing some of the ways they have reacted to your OCD. Specifically: Family members must stop imitating your rituals and avoidances. For example, they must not wash excessively for you or repeatedly check doors and electrical appliances. Family members must stop offering assurances about OCD-related concerns. For example, your family should not give you reassurances if you ask questions such as Did I kill my cat? or Should I call the police to make sure I did not hit a pedestrian while driving? Instead, they should remind you that giving you assurances will jeopardize your program. These guidelines are applicable to your friends, spouse, children, parents, siblings, etc. If you are living alone, think about whether you involve your friends and relatives in your OCD. If so, inform them about your program and tell them about the new guidelines. Selecting a Supportive Helper During your program, you are likely to become distressed when you do your exposure practice and when you resist urges to do rituals. It can be helpful to enlist a family member or friend who understands what you are trying to do and who is willing to be supportive. Social support might make the distress that you experience during your program easier to tolerate. Often one person cannot be available all the time, so it is practical to select several helpers and to arrange with them the time of day that each one will be available. It is essential that you inform your helpers about what your exercises are and what rituals you are trying to stop. For example, if you have both checking and 48

57 washing rituals and you choose to focus first on contamination and washing, your helper should know about your plan. Otherwise, the individual may try to help you with your checking before you are ready to work on those behaviors. The following rules can guide you in selecting helpers: They should have an optimistic attitude toward you and your program. They should have the time to help you. They should be available for pleasant social activities such as walking, conversation, shopping, etc., that can help you resist urges to ritualize. They should not be coercive or derogatory if they notice that you slip and ritualize. Instead, they should remind you about your program and offer to help you distract yourself from the urges. Beginning Exposure and Ritual Prevention As noted earlier, you can choose to do your treatment program more intensively or less intensively. Several considerations will dictate how intensive your program should be: the severity of your symptoms, how urgent it is for you to get relief from your symptoms, and how much time and effort you can devote to your program. If your OCD symptoms are quite severe, that is, the symptoms cause you considerable distress and you spend more than 2 hours per day on your obsessions and compulsions, you should seriously consider a more intensive program. Even if your symptoms are not that severe but you wish to obtain relief immediately, an intensive program is preferable. If your symptoms are not severe and you cannot devote the daily investment required for an intensive program, a more gradual approach is indicated. The material that follows will guide you through an intensive program, then suggest how to modify the intensive program for a more gradual approach. The intensive program recommended at the Center for the Treatment and Study of Anxiety at the Allegheny University of the Health Sciences/Medical College of Pennsylvania includes 15 exposure practices of 2 hours each over 3 weeks, plus 2 4 hours of daily homework. Sessions usually begin with imagery practice that involves imagining disastrous consequences that you fear. There are two reasons to do exposure in imagery. First, it is often easier to face a fear in reality if you have already confronted it in your imagination. For example, imagining yourself touching a toilet seat is less difficult than actually touching it in reality. Thus, imagery prepares you for the time when you will confront a situation in reality. Second, only in your imagination is it possible to confront feared disasters, such as hurting someone you love or causing your home to burn down. 49

58 After about 45 minutes of imagery practice, you confront a real situation or object that triggers your urge to ritualize. This is where the ritual-prevention component of the program becomes important. Once you have deliberately provoked the urge to ritualize, you prevent yourself from engaging in any rituals. Exposure is done intensively over the 3-week period, but you begin with situations that produce a moderate level of anxiety and gradually confront more and more difficult situations. Once you get started with the exposure, a new, more difficult situation is added daily. After a week, you are likely to be ready to confront the most disturbing situation. During the second and third weeks of your program, new situations are incorporated into your exposure exercises. If you start with situations that produce very little distress, you will waste time because confronting such situations will not teach you much. At the same time, it is inadvisable to start with situations at the top of your list, because they can cause overwhelming distress and make it difficult to correct your mistaken ideas about harm. 50

59 Chapter 5 Model Exposure Programs This chapter describes model exposure programs for various kinds of obsessions and compulsions. The case models are composed from experience with many different clients; they are not factual descriptions of any single client. (This way of creating case examples focuses on the pertinent issues while still protecting the anonymity of individual clients.) A Model Exposure Program for Washing Rituals Individuals with washing rituals usually wash because they feel contaminated by something. The sense of being contaminated is distressing and provokes urges to wash or clean to get relief. Some people think that contaminants will cause illness or death to themselves or others. Others worry that their anxiety about the contamination will mount until they have a nervous breakdown. People who are especially concerned with disasters related to contamination should include imaginal exposure in their programs, while those who are concerned with everlasting anxiety should concentrate on actual exposure. (The model described here includes both imaginal and actual exposure.) An Intensive Exposure Exercise Schedule for Washing Lee felt contaminated by bodily fluids and fears that contact with them would make her sick. This fear led to many different problems for her, aside from the bad feeling itself. Because Lee feared bodily fluids, she avoided contact with people. She believed that people were rarely careful enough about cleanliness after using the toilet; therefore most people and whatever they touched were contaminated with toilet germs. Of course, avoiding people limited the number and quality of relationships that Lee could sustain. She got into conflicts with her family because they felt burdened by her rule that they scrub their hands after touching any nonsterilized surface. They didn t visit her very much because the conflicts were so distressing. Lee avoided visiting her family because their 51

60 homes were not clean enough for her. It was hard for friends and family to enjoy time with Lee because she frequently became distressed about cleanliness, asked questions about it, and insisted on interrupting activities for hand washing. Lee s friends had drifted away from her because of these difficulties. She therefore spent much of her time alone, when she was especially prone to dwelling on her obsessions. Lee liked dogs and would have liked to have one for company, but she knew that she couldn t control what the dog touched, so she was unwilling to let a dog roam around in her home. Her loneliness was a strong motivator for her to pursue an exposure program for her OCD, even though the prospect of exposure scared her. Lee s program included imaginal exposure to bodily fluids and to the fantasy of getting sick because of this, actual exposure to things that had been in contact with bodily fluids, and refraining from washing and cleaning. Lee s hierarchy of feared situations and their SUDs ratings are listed here: Touching the office floor 50 SUDs Touching a telephone 65 SUDs Sitting on a chair in a restaurant 65 SUDs Sitting in a chair in a hospital 70 SUDs Shaking someone s sweaty hand 80 SUDs Touching a toilet seat in public bathrooms 85 SUDs Touching a spot of urine on a towel 100 SUDs Ritual Prevention Because Lee spent too much time washing and cleaning in order to neutralize contamination, she restricted the use of water on her body. For periods of 3 consecutive days for the first 2 weeks of her program, no hand washing, rinsing, or wet towels were permitted. The use of creams and other toiletry articles (bath powder, deodorant, etc.) was permitted because Lee did not feel less contaminated after using them (they were not decontaminators ). Shaving was done by dry electric shaver. Lee could drink water or use it to brush teeth, with care not to get it on her face or hands. Supervised showers were permitted every 3 days for 10 minutes each, including hair washing. Supervision usually entailed the supportive helper monitoring the length of the shower and notifying Lee to stop when the 10 minutes were over. Before starting her program, Lee would first wash the spigots in the shower, then wash her hands, and only then wash the rest of herself. During her program, she was not allowed to wash the spigots, nor was she allowed to wash her hands in the shower before washing the rest of her body. Also, she was not allowed to wash her hands last, at the end of her shower. Lee s mother agreed to be the supervisor. She was available to monitor showers and to help Lee if she had difficulty controlling a strong urge to wash by staying 52

61 with her until the urge decreased to a manageable level. If Lee s mother noticed any violations of the ritual-prevention rules, she reminded Lee that ritualizing would strengthen the OCD and that she should discuss the problem with her therapist. Lee s mother was allowed to help her stop doing a ritual with a reminder about the importance of ritual prevention in achieving relief from OCD but was not to argue with Lee or use physical force. During the first week, Lee s mother timed the showers for her and signaled when the time was up. During the second week, Lee timed her showers herself, using a kitchen timer set to ring after 10 minutes. Intensive Exposure One Day at a Time Day 1. On the first day of the exposure program, Lee touched with her hand the office floor where she works, and put her car keys on the floor and then put them in her purse. She also began her ritual prevention and so did not wash her hands afterwards. It took several hours for her to get used to her dirty keys and hands. Day 2. Lee repeated the exposure exercises that she completed on day 1 and, in addition, picked up the telephone receiver without using a handkerchief or tissue and held it up to her face as if she were using it for a 5-minute conversation. She repeated this exercise about 10 times during the day without washing her hands at all during this time. When she was not holding the telephone, she carried with her a tissue that she contaminated by touching it to the mouthpiece of the telephone. Day 3. Lee repeated the exercises from days 1 and 2 and, in addition, went to a fast-food restaurant and sat in a chair at one of the tables that had not been cleaned since the previous customers left. She took a napkin from the dispenser and touched it to the surfaces of the table and the chair seat. She carried this napkin around during the day and touched it to her face. On returning home that day, she touched the napkin to the doorknobs, light switches, dishes, flatware, and bedsheets. She continued to find items in her apartment to touch with the napkin until she felt that the whole apartment was contaminated. This exercise turned her home into a place to practice exposure for her, rather than a place to avoid contamination. She did no washing or cleaning on day 3. Day 4. In the morning, Lee took a 10-minute shower that was timed by her mother. Then she recontaminated herself immediately by touching the napkin that she had used on the day 3 to contaminate her apartment and resumed the no-washing routine. Later that day, Lee visited a crowded hospital emergency room and sat in a chair in the waiting area. She noticed that one of the other people waiting there was dressed in torn, dirty clothes. She deliberately sat in one of the chairs near that person. She touched some of the seats in the waiting room with her napkin and took it with her to recontaminate her apartment, as she had done on day 3. She also visited a neighboring friendly dog and petted its back, 53

62 after which she touched the contaminated napkin to the dog so that it would pick something up from the dog. Day 5. Lee began to confront her concerns about sweat. She attended a religious service that day and shook hands with many members of the congregation, after which she unobtrusively touched her hands to her face, hair, and clothes. This produced a SUDs level of 75. This was a little less distressing than she had anticipated in her initial estimates, and the distress decreased within 20 minutes to 40 SUDs. Then she tried a more difficult exposure to sweat. She visited a downtown area where some people could be found living on the streets. She gave one of them some money and shook hands afterwards, then touched her face, hair, and clothes with the hand that had touched the street person s sweat. This produced distress rated at 85 SUDs, which declined to 50 SUDs after about an hour, then to 25 SUDs by the end of the day. At home, she contaminated the house by touching her hands to various objects and surfaces there. She did no washing or cleaning on day 5. Day 6. Lee was ready to focus on contact with toilets and urine. Starting with her own bathroom, Lee placed her hands on the toilet seat and kept them there until her distress decreased to 40 SUDs. She then touched her hands to her face, hair, and clothes, as she had done in the previous exercises with other contaminants, and used her hands to contaminate the rest of her house. When she had completed this exercise, she visited a nearby restaurant and touched her hands to the toilet seat there. She also sat on the toilet seat without first covering it with paper. Then she returned home and touched her hands to various places around the house. This exercise produced distress rated at 90 which decreased to 50 after an hour. Lee then went to the restaurant again and touched a particular spot on the toilet seat that had a yellowish spot on it. She returned home and repeated the exercise of touching her hands to various places in the house. Her SUDs level was 100 and decreased after 2 hours to 55. After 2 more hours, it decreased to 30. She did not wash or clean on day 6. In addition to the actual exposure exercises described above, Lee practiced imaginal exposure. She prepared a story for each exposure situation on her list. The story described the situation and her fear of what would happen if she confronted it and did not ritualize. For example, before Lee did the exposure in the restaurant bathroom, she wrote a story describing what she would do and included the harmful consequences she feared would follow. In her story, shortly after exposure to the spot of urine, she began to have intestinal cramps because she had caught a disease from the germs she had picked up from the public toilet. She then experienced diarrhea, vomiting, nausea, and fever. She had to be hospitalized, and the physicians did not know what treatment to give her. She practiced imagining this story for 45 minutes before she did the actual exposure with the public toilet. During the imagery, her SUDs level increased to 70, then decreased gradually to 40. For another imaginal exposure, Lee imagined that she sat down on the floor and got dirt and germs from the floor on herself. (See Lee s imagery script for touching a dirty floor.) 54

63 Lee s Imagery Script: Exposure to Contaminated Floor You can see that the carpet is not very clean, and you tense up immediately and feel your heart racing as you look down at the floor. There are little bits of lint and some dark stains on the floor. You realize that people walk on very dirty surfaces and then track the dirt onto the carpet. The carpet is full of germs from people s shoes. You figure they must have walked on streets and sidewalks and grass where dogs have urinated and defecated. You know that people aren t that careful where they walk and don t wipe their feet carefully when they enter the building. You don t want to sit on the dirty floor. You really don t want to do it, but you know it is important to do it so that you can get relief from the OCD symptoms. You just sit down onto the floor. You don t want to touch it with your hands, but you put one hand on the floor for balance as you sit down, and it feels pretty gritty. You look at the palm of your hand and see some hair stuck to it. You know that your hand and your clothes are dirty now. You re wondering if you got germs from feces on you from touching the floor. You think that they must be there because so many people have walked on this floor and you can tell that it has not been carefully cleaned. You break out in a sweat as you realize that you are not going to wash after having touched the floor. You feel like getting up and washing your hands, but you aren t going to do it, and you feel very uncomfortable about this. You worry that you re going to get sick from the germs. Before confronting each actual exposure situation on the list, Lee practiced imaginal exposure using a story that matched the actual exposure that she was preparing to do. Sometimes, when the distress was especially high or slow to decrease, she practiced imaginal exposure for 90 minutes instead of 45 minutes. Practicing the confrontations imaginally and including the fantasies of harmful consequences until her distress decreased during her imagery helped Lee to confront the situations in real life. As noted above, at the same time she started her exposure schedule, Lee began to try very hard to stop her ritualizing. She began by giving up washing completely, except for a 10-minute shower every third day. She used only a little soap when she took her shower and washed each part of herself only once. She was careful not to do any repetitive washing. She did not prewash her hands before showering, nor did she prewash the spigots or shower stall. After she had completed her most difficult exposure exercises, the urge to ritualize had decreased substantially. By the third week, she resumed regular washing but in a limited way. She showered daily for 10 minutes and washed her hands only when they were noticeably soiled (i.e., clearly looked, felt, or smelled dirty without close inspection). Hand washes were limited to 30 seconds, and she did not routinely wash after she used the toilet. Immediately after her hand washes, Lee touched the contamination napkin that she was using for her exposure exercises. 55

64 During the second and third weeks of Lee s exposure program, she continued to practice daily the exposure exercises that she had done on days 1 6 and continued to follow her schedule for limited hand washing and showering. In addition, she extended her exposure practice by visiting public toilets in various settings, such as shopping malls, different restaurants, office buildings, and a local airport. By the end of the 3-week intensive program, her obsessional distress had decreased to an average of 15 SUDs for sitting on public toilets, so that she could stop scheduling daily exposure practice. However, in her daily life, Lee tried to notice whether she reacted with distress about contamination in situations that used to bother her. If she noticed distress, she used it as a signal to do an exposure exercise with the situation and to repeat this exercise until it was no longer distressing. In addition, she continued to follow a routine of limited washing and showering, as she did during the last part of her intensive exposure program. (Review Chapter 4 for ritual-prevention rules for individuals with washing rituals.) Modifications of the Intensive Program If you do not have severe obsessions and compulsions (less than about 2 hours per day) and you cannot devote the several hours per day required by the intensive program, you can create your own, more gradual program. However, as in the intensive program, you should complete all the steps of preparing for the program before you can start the exposure practices and the ritual prevention. These include identifying your obsessions, compulsions, avoidance, and feared harmful consequences and writing them down on the respective forms. Create a hierarchy of the main situations that cause you to feel contaminated and provoke your urge to wash and clean. A Nonintensive Exposure Exercise Schedule for Washing Once you have made a list of the situations that trigger obsessional distress and ordered them roughly according to the amount of distress they provoke, you need to make a schedule to set the pace for the exposure exercises you will do. If your OCD is very mild and you have only a few situations that bother you, scheduling is straightforward. Decide how many days each week you can practice, and set aside a specific time on each of those days for your program. You should practice at least once per week. Infrequent practice will not be helpful. As with the intensive program, you should confront each distressing situation long enough to notice the distress decrease at least somewhat. A rule of thumb is that minutes are required for a useful practice session. Also, as in the intensive program, it is advisable to begin with a moderately distressing situation. If your first exercise is extremely easy, you won t profit much from it, and if it is extremely difficult, you may find the practice discouraging. If your OCD is more complicated, such that several different types of contamination obsessions bother you, you should divide them according to how disruptive they are to your life, and begin with the most troublesome. For 56

65 example, suppose you are concerned with contamination from household chemicals, bodily fluids, and auto exhaust fumes. If the concern with bodily fluids interferes most with your day-to-day living, you should begin your program by confronting situations related to bodily fluids. Once you have made considerable progress, and situations involving blood, urine, and feces do not trigger disruptive distress, you should proceed with another area. A potential problem with a nonintensive exposure program is that, between practice sessions, you could lapse into avoidance of the situation that you have confronted during practice. This can undo the progress you have made. This problem does not occur much in intensive programs because you confront the same situation daily. To get around the problem, you should not avoid a situation you have confronted during exposure practice if you encounter it spontaneously in your daily routine. Ritual Prevention for a Nonintensive Program As with exposure practice, the schedule of ritual prevention can also be adjusted for a nonintensive program. On days that you deliberately confront contamination, you should not wash or clean at all afterwards that entire day. On other days, you should never do any ritualized washing or cleaning, but you can wash according to the rules for normal washing given in Chapter 4. In brief, this means that you can wash if there is easily noticeable soil but not to reduce obsessional distress about contamination. If you have difficulty knowing how to wash normally and you have a therapist or supervisor, discuss this issue with them. If necessary, they can demonstrate a brief, practical way of washing. Showering itself can be demonstrated if the model gets into the shower stall without removing clothes and goes through all the motions of a shower without actually showering. You can practice while the supervisor watches, then take the actual shower after the supervisor leaves. Remember, if you ritualize between practice days, you undo progress that you are making in your program because you are strengthening the rituals that you are trying to weaken through the practices. A Model Exposure Program for Checking or Repeating Rituals Individuals with checking and/or repeating rituals typically ritualize to try to keep bad things from happening. Common concerns of individuals with checking rituals are being responsible for fire, flood, hit-and-run auto accidents, mistakes of all kinds, burglary, and illness. Some individuals purposely repeat actions to cancel or undo a fearful thought that has come to mind or superstitiously to keep the bad event from occurring. Other individuals with repeating rituals continue until an action feels right to them, but there is no thought of preventing harm; rather, the repetition is aimed at reducing discomfort about doing something wrong. 57

66 Often enough, a person has both checking and repeating rituals. Nevertheless, neither the checking nor the repeating does much good to prevent harm, nor do the rituals provide lasting relief. More urges to check or repeat follow. The chain of distress and ritualizing can last for hours and typically ends because of exhaustion or because of outside demands but rarely because the obsession has been eliminated. An Intensive Exposure Exercise Schedule for Checking/Repeating Marty feared harming others when driving his car and via use of appliances, locks, lights, etc., at home. He was especially worried about his 4-year-old son, fearing that he would drop the child on a concrete floor or that the boy would fall downstairs. To prevent these catastrophes, Marty checked a variety of events repeatedly, including the area surrounding his car (both directly and in his mirrors), his son s whereabouts and condition, and the condition of appliances, locks, and lights at home. He also checked for mistakes in paperwork. The harming obsessions and checking rituals caused many practical problems for Marty. Because he spent so much time checking and got stuck checking when he should have been getting on to something else, he almost always took too long to do anything. He couldn t get very many things done during the day, and he was late getting everywhere. Marty and his wife owned their business, a small store that specialized in religious books and church supplies, so he had been able to continue working, but his lateness caused him to lose customers. He almost never opened his store on time, because he drove to work and wasted a lot of time driving back to check for accidents. Marty s wife also worked at the store, and they brought their son there during the day. They were having financial problems because the store wasn t kept open enough. Marty also had problems filling mail orders because he was concerned that he would make a mistake with the order. He was afraid to send out orders until he had checked them thoroughly. Marty sometimes avoided, for several days, sending out an order that had already been packed, because he hated to get stuck doing the long checking rituals that he did with each order. Of course his customers were sometimes very impatient with the delays and found another mail-order supplier. His wife tried to make up the work that Marty didn t do, but she couldn t keep up with this and also look after their son. Marty had trouble looking after the boy because he got obsessions about the child s getting hurt in some way. The boy didn t understand why his father didn t spend much time with him. Marty s wife had become so distressed with the financial and family problems the OCD caused that she had started insisting Marty get some help with the OCD. She obtained information about OCD and its treatment and gave it to Marty. This helped Marty understand how much OCD was disrupting his life and that it was possible to obtain relief from the OCD symptoms. 58

67 Marty s exposure hierarchy was as follows: Using lights and stove 50 SUDs Opening doors and windows 60 SUDs Flushing toilet with cover closed 70 SUDs Son playing near open stair gate 75 SUDs Carrying son over concrete 85 SUDs Driving on crowded roads 100 SUDs Refraining From Checking Rituals Beginning with the first session of exposure and response prevention, Marty refrained from all ritualistic behavior. Only routine responsible behavior was permitted (e.g., it was OK to lock the door upon leaving, but there was no checking to confirm that it was locked.) At home, refraining from rituals was supported by Marty s wife, who had agreed to help him and had been instructed by Marty and his therapist about how to help. She agreed to be available at Marty s request whenever an urge to check was difficult to resist. When Marty asked her to help, she reminded him that his program required that he try as hard as he could to resist the urge, and she stayed with Marty until the urge passed. Ritual Prevention At home, you may enlist relatives or friends to help you refrain from rituals. You should teach them about the guidelines for ritual prevention described in Chapter 4. Arrange for your support person to be available at your request whenever an urge to check is difficult to resist. They are to stay with you until the urge decreases to a manageable level. Intensive Exposure One Day at a Time Day 1. Marty s first exposure was imaginal: He imagined that a fire occurred because he had not checked the lights properly (see Marty s imagery script for this exercise). Afterwards, for actual exposure, he turned the lights on and off once, turned the stove on and off once, and opened and closed doors and windows once. After each action he left the room immediately and focused on having not checked these objects. Marty repeated this procedure throughout the session using different switches, appliances, and windows. Each exposure exercise was done in a different area of the house so that accidental checking of completed tasks would not occur. 59

68 Day 2. Exposure to situations from Day 1 was repeated, but with the therapist not in the same room when each task was performed, so that the client would not count the therapist s acquiescence as indicating that the client had indeed done nothing harmful. In addition, Marty brought a small box of mail-ordered items to the office, sealed it, and left it at the mail-drop. Day 3. The previous day s exercises were repeated. In addition, Marty allowed his 4-year-old son to play near the stair gate without his supervision. Day 4. A new imagery script was introduced: Marty s dropping his son on the concrete floor. Also, the previous day s actual-exposure exercises were repeated. In addition, Marty held and then carried his son over the concrete floor and mailed out an order at the store without unpacking it to check the contents. Day 5. The previous day s exercises were repeated. Then the therapist accompanied Marty as he drove on the highway. The return trip took a different route than the outbound trip so that Marty could do no incidental checking for accidents. The center-mounted rear-view mirror was displaced so that it did not focus on the area behind the auto. Marty used the door-mounted rear-view mirrors only for lane changes. Day 6. A new imagery script was introduced: an auto accident. Marty again drove on the highway as in day 5, but without the therapist present. He returned to the clinic after the drive to describe his performance and experience during the exercise. Days Marty continued exposure to all of the above situations under various conditions, with particular emphasis on the most difficult items. Variations of the driving task included driving at night, driving in rainy weather, driving in areas crowded with pedestrians, and driving in areas crowded with children. Imaginal Exposure Marty s treatment began by confronting his most common concern, fear of fire from leaving the lights on. In the first session, he was asked to imagine a disaster happening because of his failure to check. Marty s Imagery Script: House Fire You forget to turn the lights off. You leave the house without checking the lights or any other electrical appliance and decide not to go back and check. After 2 hours, you return home. As you walk up to your house, you break out in a sweat as you see three fire engines nearby. You realize that something terrible must have happened. As you get closer, you see your wife and children outside, and smoke is pouring out of the house. You feel terribly guilty because you know you could have avoided this destruction by being more responsible about the electricity. 60

69 After three imagery sessions, Marty became less distressed with the idea of accidentally causing damage to his home and the distress it would cause to his family, so his therapy and treatment then focused on his fear of harming his son. He confronted this obsessional fear by repeatedly imagining that he caused harm to his son. Marty practiced imagining that he dropped his son on the concrete floor, and that his wife and parents blamed him for being careless and were very angry at him about it. Finally, the most feared disaster accidentally hitting and killing a pedestrian with an automobile was addressed with an imaginal exposure exercise. Marty s Imagery Script: Auto Accident You are driving along a row of houses, with many cars parked along the curb where people can step out suddenly from between the cars. You notice that the car hits a bump. What if you hit a pedestrian without noticing? You feel your heart racing, but you don t stop and check because you didn t actually see anyone get hit. As you continue to drive, you hear a siren and see the blinking lights of a police car following you. The police signal you to stop. You are arrested by the police for hit-and-run driving because someone saw you hit and kill an old woman back by the row of houses and parked cars. Each of the narrative descriptions lasted about 3 minutes, and Marty imagined them repeatedly for about 45 minutes. Marty was asked to focus especially on whatever aspects of each image provoked the most obsessional distress for him (for example: seeing his family watching the damaged house, or the idea of his responsibility for the auto accident). After his intensive program, Marty felt much better and was able to perform his daily activities without much distress or even distraction from obsessive intrusions. Four years later, his checking was minimal, lasting about 10 minutes a day. This involved making sure that the windows and doors at his work place were locked, because he was actually responsible for locking all offices and the front door at the end of the day. Marty felt that this checking was practically useful, and he did not experience distress about it. A Nonintensive Exposure Exercise Schedule for Checking/Repeating Developing a nonintensive program for checking/repeating follows the same general considerations involved for washing rituals. Use the list you made of the situations that trigger obsessional distress, ordered roughly according to the amount of distress they provoke, and make a schedule to set the pace for the exposure exercises you will do. A nonintensive program proceeds more slowly than the intensive program: You don t challenge yourself as much each day, and you don t improve as fast. 61

70 If your OCD is very mild and you only have a few situations that bother you, scheduling is straightforward. Decide how many days each week you can practice, and set aside a specific time on each of those days for your program. You should practice at least once per week. The more frequently you practice, the faster you will make progress in reducing your OCD. If you practice very infrequently and your progress is very slow, you may lose faith in the treatment method. If you lose faith in the treatment method, you will probably give up on the program and not make any more progress with it. As with the intensive program, you should confront each distressing situation long enough to notice the distress decrease at least somewhat. Remember, the rule of thumb is that minutes are required for a useful practice session. Also, as in the intensive program, it is advisable to begin with a moderately distressing situation. If your first exercise is extremely easy, you won t profit much from it, and if it is extremely difficult, you may find the practice discouraging. If several different types of checking/repeating issues bother you, it is probably best to divide them according to how disruptive they are to your life, and begin with the most troublesome. That way, you will be working first on the things that are most important to you. Reducing obsessions that make the most difference in your life is a good way to keep yourself motivated to continue with your program. It can be hard to keep up the discipline of practicing regularly for many months, so it is good to address the most important things early. Once you have made considerable progress with the most disruptive obsessions, your success may inspire you to apply the exposure methods to the less troublesome obsessions. As noted earlier, watch out for the possibility of lapsing into avoidance of the situation that you have already worked on if there are some days between practice sessions. One way around this is to confront, at least once daily, all situations for which you have already done practices, even if you are not working on new situations daily from your list. Also, you should not avoid already practiced situations if you encounter them spontaneously in your daily routine. Ritual Prevention for a Nonintensive Program for Checking/Repeating Unlike your exposure schedule that can be done at a slower pace in a nonintensive program, refraining from checking and repeating rituals should not be done gradually. This is because every time you do a checking or repeating ritual, you are strengthening the OCD symptoms. Continuing to do rituals while you are doing your nonintensive exposure program is like bailing water out of a boat with one hand while pouring it in with the other. In other words, each time you ritualize, you reverse what you have achieved when you resisted an urge to ritualize. In brief, this means that you must at least try to refrain from all ritualized checking and repeating. You can check or repeat something that is practically necessary (such as whether your child s diaper is soiled, or rewriting your signature if the ink does not flow out of the pen the first time), but you should not do any unnecessary checking or repeating. 62

71 Getting the Most Out of Exposure for Checking/Repeating Remember that not just any kind of exposure is helpful for OCD. To be beneficial, exposures must provoke the obsessional distress and must last until the distress decreases on its own without rituals. It can be harder to develop long, continuing exposure exercises to combat checking/repeating obsessions than for contamination fears. It is usually a simple (but not easy) matter to touch or hold a contaminant for a long time to conduct a long exposure session. However, situations that prompt urges to check often don t last long enough to allow a long exposure practice. Mailing a couple of envelopes properly takes only a few minutes, and the situation is then finished. Locking a door or closing a water tap requires only a few seconds, and no more activity is needed. If you engage in checking rituals and you remain in the feared situation for a long period of time (e.g., standing by the mailbox for 20 minutes after having mailed an envelope; standing by the door for 20 minutes after having locked it), you can defeat the purpose of the exercise because staying in the situation leads to automatic or unintentional checking. Often, simply staying in the situation for a long time while no harm occurs is a kind of checking that reduces your distress and thus minimizes the challenge (and usefulness) of the exposure practice. Only if you leave the situation without checking will the obsessional distress be fully triggered, and the best exposure exercises are ones that last long enough for the distress to decrease on its own. To make the most of exposure exercises directed at your checking concerns, you can do two things. First, each exposure exercise should usually include several exposure situations that you enter and leave promptly, without returning to them for quite a while, if ever. The long exposure for you is then the long period of time after you leave the situation during which you do no checking. Second, you should repeatedly remind yourself what risks you are taking by not going back to check. This is another way to intensify the exposure practice and keep it going for a long time after you have left the situations. The following examples of low-risk actions that you can do purposely illustrate the general way to do exposures for checking concerns. 1. If you fear that the oven will cause a fire, you can practice turning on the oven and not checking it for an hour. You can even give yourself a harder exercise by purposely leaving the house for an hour or so. Modern ovens are built to be safe when left unattended and are even equipped with timers so that you can slow-cook something for several hours without checking it at all. 2. Similarly, if you fear leaving on lights or other ordinary electrical appliances that are safe to leave on, such as a radio or fan, practice leaving these objects on for extended periods without monitoring. Radios, televisions, lamps, fans, refrigerators, air conditioners, and 63

72 many other appliances are routinely and safely operated by timers or thermostats when people are away from home. They provide temperature control or give the appearance of occupancy to potential thieves. Of course, appliances can be abused, and exposure practice should not involve very risky practices, such as placing electric heaters against curtains or putting fingers into working appliances. However, it is routinely the low-risk situations that provoke obsessional fears, and it is not difficult to develop many low-risk exposure exercises to practice. 3. If you fear that broken glass has fallen to the bottom of the dishwasher, you can place a broken dish into the bottom of the dishwasher, then wash a load of dishes. 4. If you fear miswriting a check, you could purposely leave one letter out of the payee s name or out of the signature. 5. If you fear making mistakes in conversations, you could intentionally misspeak without correcting the mistakes. 6. If you are perfectionistic and fear performing actions imperfectly, you should intentionally build minor imperfections into every act you do during a designated exposure period. These are just a few examples of the type of purposeful low-risk activities that can constitute useful exposure exercises to help alleviate urges to check. As described earlier, people with checking rituals try to prevent disastrous consequences that may result from neglect. Individuals who check are chiefly concerned about disasters they can cause. Of course it is impractical to create actual disasters as exposure exercises. Therefore, imaginal exposure to disasters is used when checking to prevent disasters is an issue. A Model Exposure Program for Hoarding Rituals If you have difficulty with hoarding, the details of your program will probably look quite different from the ones for washing, checking, and repeating, but the basic principles are still the same. First, it is important to figure out how your hoarding works. Some people who hoard spend a lot of time collecting useless junk. On the other hand, other people with hoarding rituals spend little or no time on ritualized collecting, and their difficulty appears mainly to be avoidance of discarding. If your hoarding consists of actively collecting junk, you should consider collecting to be a ritual that you must stop. If you mainly avoid discarding, your ritual may be primarily mental reviewing of the pros and cons of throwing each thing away, or it may be checking to see if you are throwing away something important or potentially useful. This seems to be a problem with perfectionistic sorting. When decision making about 64

73 discarding is extremely distressing, some people simply avoid discarding. That s how the hoard of things accumulates for them. Other people with hoarding behaviors have magical ideas about discarding material. For example, a person might not want to discard fingernail clippings or hair for fear that this would cause some harm to occur. Some hoarding is related to moral scrupulosity, a perfectionistic avoidance of wasting anything. You can see from these examples that you will need to figure out the nature of your obsessions so that you can make a list of exposure exercises that get at the fears you actually have. There s no point developing imagery scripts about your causing someone to die by discarding old newspapers if you don t have that superstition. Also, if you don t spend time actively collecting useless junk, you don t have to pay attention to that in your program. For many individuals who hoard, a practical program involves two components: discarding a large amount of material, and practice in nonperfectionistic sorting. These are related but somewhat different tasks, and it is useful to think about them separately, so that the overall program doesn t seem overwhelming. How much junk have you accumulated? Suppose you have 1000 pounds to be discarded, and it is piled in several rooms. If you try to sort through all the material carefully, you will almost surely give up before very long because the job would be too distressing and take up too much time. Instead, you will have to discard the junk quickly, without sorting it into things to keep and things to discard. The act of throwing things out without sorting through them is an important exposure practice. You may need helpers just to carry all the junk out of your rooms, or you might have to rent a truck or dumpster to haul away the junk. Once you get rid of your junk without sorting, you may still need to learn to sort and discard without distress or rituals. If so, your exposure program should include such practice. To do this, arrange to sort/discard small amounts of material at a time. Keep only material that will definitely be useful in the near future. If you don t learn to sort/discard without rituals and distress, you will immediately start to pile up junk again even though you put a lot of effort into throwing out your hoard of junk as part of your exposure program. An Intensive Exposure Exercise Schedule for Hoarding Nader was concerned with mistakenly discarding items that might be useful at some time in the future, and he had accumulated large amounts of newspapers, magazines, old clothing, mail, store receipts, and used packaging material. There was a large number of technical magazines about computers, computer programs, and computer parts. The hoarded material was stored in his apartment, in rented storage bins at another location, and in his car. In addition, his refrigerator was packed so tightly with stale food items that there was no room for edible food. 65

74 Nader s OCD had not stopped him from being a successful computer consultant. Except for his hesitation to delete old computer files that were no longer of use, the hoarding did not much affect his work. It did, however, affect his mood and his social life. Nader felt that his apartment was disgusting and that he was a disgusting person because he hadn t cleaned it out. He was actually a friendly and pleasant individual and had some friends, but he avoided letting anyone get to know him well because he was ashamed of himself and his apartment. He hadn t let anyone in his apartment for several years. Once he had a problem with an electrical outlet but fixed it himself because he did not want the landlord to discover the mess in his apartment. He was afraid that if the landlord found out about the mess, he would be evicted because the junk was a health and fire hazard. The apartment was so full of junk that Nader didn t spend much time there anymore. He spent most of his time at his job, working late into the evenings and on weekends. He liked his work but would rather not have been spending so much time working because he felt that he didn t have much of a life outside of his job. The only thing he did at home was sleep and use the bathroom. He had been able to keep junk off his bed so that he could sleep there. The bathroom had piles of junk, but he could still use the shower, sink, and toilet. Nader s exposure items were as follows: Discard old newspapers in office 50 SUDs Discard old magazines in office 55 SUDs Discard old packaging material 57 SUDs Discard items of used clothing 60 SUDs Sort box of receipts and discard most 75 SUDs Sort new mail and discard most 75 SUDs Discard junk stored in car 85 SUDs Empty refrigerator and discard all without sorting 90 SUDs Empty storage bins and discard 95 SUDs Empty junk rooms at home and discard 95 SUDs Intensive Exposure One Day at a Time Day 1. Nader brought a box of old newspapers and magazines to the therapist s office, and together, he and the therapist dumped all items into a trash bin. The therapist showed Nader how to discard quickly and without careful inspection of each item. Only a quick look at the item while it was being discarded was permitted. Things that were obviously valuable were kept, but there didn t happen to be anything of value in the box of newspapers and magazines. 66

75 For homework, Nader chose one box of newspapers and magazines at home and discarded them in the same manner as had been done with the therapist at the office. Nader was assigned to bring another box of material to the office on day 2, as well as a large bag of old wrapping material. Day 2. Nader discarded another box of old magazines and newspapers, as well as a bag of old wrapping material. The therapist accompanied Nader to a rented storage bin and together they chose one box of junk to discard immediately. For homework, Nader discarded another box of newspapers and magazines at home, as well as a box of used packing material. Two boxes of old clothing and a box of store receipts were to be brought to the office session on day 3. Day 3. Nader brought more boxes of old clothing and discarded them during the session. Training in nonritualized sorting/discarding began. The therapist demonstrated sorting of store receipts for discard. All receipts were discarded except those for costly appliances that were under warranty. If the receipt was for less than $50, it was discarded immediately. The decision for each receipt was made instantly; no prolonged inspection or deliberation was allowed. If there was any doubt about whether to keep a particular receipt, it was discarded. Nader learned when in doubt about discarding, take a chance. Any new mail received since day 1 of treatment was to be brought to the next meeting, as well as a checkbook. Day 4. The therapist demonstrated sorting and discarding of recently received mail. Advertising items were discarded without opening them (e.g., an envelope labeled valuable coupons inside, a booklet of advertisements for a local supermarket). Other items were opened quickly, scanned for 5 seconds, and discarded unless they were bills, checks, or personal letters. One utility bill was discovered, and a check was immediately written and the payment mailed during the session. The therapist accompanied Nader to his car, and they drove to a nearby trash bin belonging to the hospital. The therapist demonstrated rapid discarding of old newspapers, bottles, aluminum cans, magazines, old clothing, and food wrappers from the trunk and seating areas of the car. Quickly and without sorting through it, Nader then discarded about 75% of the junk stored in the car. For homework, Nader discarded the remaining 25% of the junk stored in the car. In addition, he purchased a box of heavy-duty garbage bags for the next session. He immediately sorted and discarded or answered any new mail that he received at home. Day 5. The therapist visited Nader s home. Together, they emptied 75% of the contents of the refrigerator into plastic bags and carried them to the apartment building s dumpster. For homework, Nader rented a handtruck and brought it to his apartment for use during subsequent sessions. Day 6. The therapist met Nader again at his home. Together, they loaded the handtruck with boxes and bags of newspapers, magazines, and other junk, 67

76 and carted it to the dumpster of the apartment building without any detailed inspection or sorting of the contents of the bags and boxes. Any box or bag containing clothing was retained for subsequent sorting. Approximately 5% of the stored junk was discarded during this session. For homework, Nader spent 1 additional hour hauling junk out to the dumpster. Days The exercises done on days 1 6 were continued and expanded. Most of the remaining time was spent on daily discard of large quantities of hoarded material from the apartment and the rented storage bins. The therapist visited Nader at home and at the storage bins on some days; on other days, meetings took place at the therapist s office. During these meetings, the previous and next day s homework was discussed. On some of the days, Nader arranged for friends to visit at home and at the storage bins and help carry out junk. Approximately 10% of the hoard was discarded daily, so that by day 15 almost all of the junk had been discarded. After the 15 scheduled daily sessions, Nader did any remaining discarding of junk without the therapist s help. A Nonintensive Exposure Exercise Schedule for Hoarding In some ways, hoarding lends itself more readily to a nonintensive program than do some other obsessive-compulsive patterns, such as the concerns accompanying washing or checking, because the two main tasks for people who hoard often are discarding large quantities of junk and learning to sort properly so as not to accumulate new junk. When there are many rooms or storage bins of junk to discard, the job of throwing things out can be done over a more or less extended period, depending on what is practical, without compromising the exposure program. If you want to work on your hoarding more gradually than was described in the intensive program, you could decide to discard stuff for only 15 or 30 minutes per day, or even every other day, no matter how much stuff you have. Of course the less you discard each day, the longer you will have piles of junk around. No matter how much you discard each day, however, it is essential that you learn to sort/discard in a new, nonritualistic way. Otherwise, the time you spend discarding will actually be strengthening the OCD pattern! For example, if each day you spend 15 minutes discarding, but each day get rid of only a couple of pieces of junk mail or one item of clothing because you are painstakingly analyzing what can be thrown away, this will not help you overcome the OCD. The important element in a nonintensive program for hoarding is not the number of pounds of junk that you discard each day but whether you discard it without ritualized perfectionistic sorting. The model intensive program described above involved a therapist to coach the individual on how to sort properly. Regardless of whether you try an intensive 68

77 or nonintensive program to work on getting rid of your hoarding, you may have become so accustomed to perfectionistic sorting that you have completely forgotten how to do a quick sort-and-discard of junk material. If you do not have a therapist, you may want to ask a supportive friend or relative to show you how to discard. Getting help with this from a friend can be tricky, however, because trying to sort through a large quantity of accumulated junk in a normal way will probably be impractical and overwhelming. Instead, you should learn normal sorting mainly with newly acquired material (e.g., today s mail). Five years worth of old newspapers and magazines should not be sorted at all. These should just be discarded. If you do not have a therapist with expertise in exposure treatment for hoarding to guide you, you can use this rule of thumb: If you are getting emotionally overwhelmed, you are doing too much sorting and not enough discarding. A Model Exposure Program for Ordering Rituals Ordering rituals are triggered when the individual notices particular items not in place. Exposure practice for people with ordering compulsions involves purposely disordering the parts of their environment that they have strong urges to keep in order, and leaving things disordered so that their distress decreases spontaneously. Ordinarily, an individual who engages in ordering rituals would try to decrease distress by putting things in the proper order. Some persons have superstitious concerns that something terrible might happen to themselves or to people they care about unless they order things properly. Others don t have any ideas of disastrous consequences of disorder but simply feel very uncomfortable when things aren t right. The proper or right order is very much in the eye of the beholder. What might be right for one individual with this form of OCD might feel wrong for another. Some people care more about the order of their actions than about the placement of objects in their environment. For example, it might be important for one person to arrange pens and pencils exactly parallel with the edges of the desk or table where they are placed, or to have the towels on the towel rack very even and free of creases. Another person might need to eat food in a certain order, perhaps finishing any green vegetables before going on to starch, and eating meat or fish last. Some people dress in a fixed order, or shave or shower in a fixed order. As with other OCD patterns, the problem is not that the person actually keeps things orderly in a practical way, but rather that the person is so concerned with order that it becomes impractical and distressing. Similarly, the inconsequential little habits (e.g., tie the right shoe first in the morning) that people develop are 69

78 not considered OCD symptoms just because they are done the same way every day. Only when doing things the same way each time becomes overly important, causing distress and interfering with practical matters, would these patterns become targets for an exposure program. An Intensive Exposure Exercise Schedule for Ordering Marquita engaged primarily in ordering rituals, and ordered both objects and actions. Unlike Nader in the previous illustration, Marquita arranged her apartment very neatly, with no clutter. It was very important to her that all the furniture be lined up precisely parallel to the walls. Also, whenever possible, objects were placed in symmetrical balance. That is to say, things were placed in pairs and were each equally distant from other objects, surfaces, or edges. Also, pairs of objects were, if not identical, roughly the same size. Pictures on the walls were perfectly straight, and if there were a picture on one wall, there was always one directly across from it on the opposite wall. Marquita did not have superstitious beliefs about harm that would occur if things were disordered. Rather, she just felt very uncomfortable if things weren t right. Marquita led an active life despite her OCD symptoms. She was a travel writer and did a good deal of traveling. Her OCD symptoms did, however, cause problems with other people because she was very controlling of little, inconsequential things that they did. When she stayed at a hotel, the first thing she did was to put things in order in the room. She didn t want anything moved by the housekeeping staff, and she sometimes got into arguments with them because they insisted on coming in and tidying up the room. She also had similar problems about her office at work. She didn t want anything in her office especially on her desk moved by anyone and became very angry if someone moved something. She had friends who visited her at her home, and they had learned not to move anything when they were there. She never had parties because things would get moved. Besides putting things in order, Marquita sometimes felt that the order in which she did something wasn t right. For example, she took care to put her clothes on in the right order. She always put her left arm and leg into things first, and put her left shoe on first. This wasn t just an idle habit: She actually felt pretty uncomfortable if she didn t do it that way, so she paid close attention to how she dressed. In the shower, she washed the left side first, then dried herself the same way. If she forgot to do something in order and then noticed, she started over again (e.g., got undressed, then got dressed again). Even though Marquita could manage pretty well despite her OCD symptoms, she found it very draining to pay so much attention to keeping and doing things in order. Also, she felt bad about losing her temper when people moved things in a way that didn t really cause any harm. 70

79 Marquita s exposure items were as follows: Clothes not orderly 50 SUDs Place items on tables unevenly 55 SUDs Arrange furniture at home unevenly 57 SUDs Disorganize clothes in drawers 60 SUDs Disorganize clothes in closets 75 SUDs Misfile some files in cabinet 75 SUDs Put only one vase on mantle 85 SUDs Put cushions unevenly on couch 90 SUDs Allow therapist to disorder home 95 SUDs Children move items at home 95 SUDs Intensive Exposure One Day at a Time Day 1. In the office, Marquita disordered the clothes she was wearing. The therapist suggested different ways to do this. Marquita rebuttoned her blouse so that the buttons mismatched the button holes by one button. She also let a little of the blouse stick out of her slacks on one side so that it was uneven. She unbuttoned one shirtsleeve button and left it unbuttoned, thus making it uneven. She also removed one earring so that she was wearing an earring on only one side. For homework, she left her clothes disordered, and when she dressed the next day, she disordered her clothes in a similar way. Also for homework, Marquita removed an entire drawer of clothes from her bureau to bring to the session the next day. Day 2. The therapist showed Marquita how to empty a drawer of neatly folded clothes and stuff them back into the drawer in a haphazard fashion. They dumped the drawer upside down on the office floor, and picked up bunches of clothes without folding them. Then they mixed them all up in the drawer. Also, Marquita practiced moving objects in the office and around the clinic and placing them in uneven or unbalanced positions. For homework, Marquita disorganized several more drawers of clothes in the way she had practiced with the therapist and moved objects on tables at home so that they were unevenly placed. Day 3. The therapist visited Marquita at her apartment to coach her in creating disorder there. Marquita tilted some of the pictures on her walls so that they were not perfectly straight. She removed one of the pictures and put it in a closet, so that the apartment felt unbalanced. She also moved some of the items on tables so that they were no longer lined up parallel to the edges and were not symmetrically placed on the tables. Marquita and the therapist moved the couch 71

80 a little so that it wasn t lined up properly with the other furniture and walls in the room. For homework, Marquita refrained from reorganizing her apartment, and she disordered the items hanging in her closet. As part of disordering the closet, she mixed up where the items were hanging, let a couple of items fall onto the closet floor, jumbled up the shoes on the floor of the closet, and threw a shoe and a blouse under the bed. Day 4. Instead of visiting the office, Marquita telephoned the therapist at an appointed time and reviewed her progress with yesterday s homework. The therapist instructed her to practice all the exercises from day 3 again at home and to phone the therapist in an hour to discuss how the exercises went. Marquita added one more challenging exercise to her disordering tasks: She moved the vase on her mantle to the side, making the mantle obviously unbalanced. Day 5. The therapist again visited Marquita at her home. They took the cushions off the couch and exchanged them with the chair cushions. They also left one cushion entirely off the couch, placing it on the floor by the wall. They then practiced stripping the bed and remaking it. The therapist asked Marquita to demonstrate the perfectionistic way of making the bed, then they restripped the bed and the therapist demonstrated an imperfect way to make it. The sheets were not completely even and were not tucked well under the mattress, some wrinkles were left in the blanket and spread, and the pillows were sticking out of the top. Marquita then practiced making the bed this way. Marquita gave the therapist permission to disorder various items in the apartment without asking about each one. The therapist disordered each room, one at a time, while Marquita always stayed in a different room so that she couldn t supervise or control the process. The therapist moved various things a little in each room, so that they were disordered but not seriously in the way or inconveniently hidden. For homework, Marquita asked her sister to visit over the weekend and bring her 2-year-old child, who liked to play with cushions and any other items in reach. Marquita let the child play with the cushions without reorganizing them afterward. Marquita s sister also brought plastic blocks for the child, who played with them and left them scattered all over the apartment. Marquita s sister allowed her to borrow the blocks for practice, and Marquita left them scattered around the apartment for the whole weekend. Days The exercises done on days 1 6 were continued and expanded. Most of the remaining time was spent on daily disordering. The therapist visited Marquita at home on days 6 and 8 and showed her how to start putting her apartment back in order but leaving each thing a little bit imperfect. On one of the days, Marquita arranged a visit from a friend who had a small child, so that the child could be allowed to disorder her apartment somewhat. Afterwards, Marquita left the disorder until the next day, when she was allowed to clean it up in an imperfect manner. 72

81 Because Marquita s OCD symptoms were confined to ordering, and because she followed her exposure program diligently, she completed all her exposure items within 10 sessions and was no longer bothered much by disorder. In subsequent weeks, she kept practicing being imperfect but did not have to practice creating disorder in an exaggerated way. Thus, although her program was indeed intensive, the intensive part was somewhat shorter (about 2 weeks) than those for individuals with more complicated symptom patterns. Because Marquita did not believe that any disasters would occur because of disorder, and because it was very practical to do actual exposure to the kind of disorganization that concerned her, imaginal exposure was not included in her program. A Nonintensive Exposure Exercise Schedule for Ordering If you want to work on your ordering more gradually than was described for an intensive program, you could decide to disorder things little by little, devoting less time per day (e.g., only minutes), or even every other day. Of course, just as with the programs for other OCD patterns, the less you practice each day, the longer you will be bothered by the symptoms. No matter how much disordering you practice each day, it is essential that you learn to do things imperfectly whenever you are tempted to do a perfectionistic ritual throughout the day. Otherwise, if you do some brief disordering exercises every so often, then for the rest of your day you try to get everything done perfectly, you will be strengthening the OCD pattern more than you will be weakening it with your disordering practices! It will be important in a nonintensive program not only to disorder things, but also to refrain from ritualized perfectionism. What to Do About Mental Rituals Mental rituals may be harder to overcome than overt rituals if you have difficulty telling the difference between obsessions and mental rituals. One client became distressed each time he thought about chicken soup. Just the idea of chicken soup triggered a feeling of being contaminated by chicken soup, as if he had actually touched it. To get rid of the bad feeling, he thought about detergent. The idea of chicken soup was an obsessive intrusion, whereas thinking of detergent was a mental ritual. For treatment to be successful, the client first had to distinguish the obsession from the ritual. (This is because a person uses prolonged exposure to combat obsessions and uses ritual prevention against rituals.) One rule of thumb to help tell the difference between obsessional intrusions and mental rituals is that obsessions usually trigger distress, and rituals usually temporarily relieve distress. Things can get confusing because rituals themselves can become distressing when a person gets stuck doing them, but the general rule of thumb is a pretty good one. As noted earlier, it is important to see the difference between obsessions and mental rituals because to fight obsessions, 73

82 you try to make them happen purposely, but to fight rituals, you try not to do them. You can see how it is important not to get the two mixed up in your exposure program. A behavioral ritual may seem easier to control than a thinking ritual. For example, if you have the urge to wash, you can walk away from a faucet and not wash until the urge dissipates. You can also ask for help to distract yourself if the urge becomes very strong. However, with thinking rituals (such as praying, repeating words, or repeating numbers), you can t just walk away from the ritual, because you do them mentally. No matter where you go or what you do, you can start to do the ritual in your mind. Sometimes mental rituals seem even to happen automatically. There are two main ways to work against mental rituals. One way is to turn your attention to something else when the urge to ritualize occurs. The other way is to do an exposure exercise whenever an urge to ritualize occurs. This means that you would purposely have the obsession instead of trying to get rid of it by using a mental ritual. You immediately stop the mental ritual as soon as you become aware of it and then purposely bring to mind an obsession. In other words, the exposure exercise is to replace the mental ritual with an obsession until the obsession goes away on its own. 74

83 Chapter 6 Getting the Most From Your Program Although the basic ideas (exposure, refraining from rituals) behind your treatment program are not so hard to understand, it is usually not as easy to actually do the program as it is to think about it. This chapter offers some pointers on how you might help yourself to follow through with your program so that you get what you need from it: relief from OCD. Developing the Courage to Confront Feared Situations One thing that can be difficult about this program is getting yourself to do the exposure exercises. If you find that you feel unwilling to try to do one or more of the practices because you are anxious about them, one thing that you can do is remind yourself about the thinking behind doing the exercises. The material in this chapter can help you do that. Remember that it is essential for you to confront the feared situations even though they are distressing. If you are to get relief with this program, you simply must do the exercise. It turns out that many other people with OCD have actually been able to choose to confront their fears and get relief from their OCD. It is important not to give in to temptations to put off the exposure practice, because this will slow down your progress in ridding yourself of the OCD symptoms and might even stop progress completely. The part of the exposure treatment in which you confront the most difficult situations is when people usually feel the most noticeable relief. Unfortunately, it is also during this part of the treatment that you might be most tempted to avoid a scheduled exposure exercise because you are anxious about doing it. Of course this could happen as well in the beginning period of treatment, but it seems more likely as you get to the most difficult items on your list. Only when you have done prolonged exposure to the most difficult items on the list without 75

84 ritualizing will they lose their power to provoke anxiety in you. This must be done if the exposure treatment is to be successful. Reminding yourself of these things might help you to develop the courage to do difficult practices. Dangerous Beast or Paper Tiger Sometimes a person will feel very anxious about doing a required exposure exercise because of a belief that it is actually dangerous. In this case, it is important to remind yourself that the sense of danger is a mistaken idea that goes along with the OCD, and that the exposure exercise will reduce your sense of danger. You can think of the feared exposure item as an impostor, a paper tiger that masquerades as a terrifying beast. You have to touch it to unmask it and discover that it is harmless. Only by facing up to the beast will you learn that it is really a harmless paper tiger. Confront the Most Distressing Situation Early It is usually tempting to put off exposure practices for as long as possible because they are distressing, and of course a person would prefer to put off being distressed. However, putting off your practice strengthens habits of avoidance and slows your progress. If your progress is slowed down enough, you may get tired of your program and give up trying. If you are trying to do an exposure program without a therapist and you are being unsuccessful, one option is to stop trying to do it on your own and to get a good therapist. If you have not been trying one of the helpful medications for OCD, another option is to stop your program for a while and consult a psychiatrist for medication. Perhaps the medication will either provide sufficient relief or reduce your obsessional distress enough that you could resume your exposure program. Sometimes it can be better to discontinue an exposure program than to keep feeling angry, guilty, or sad about failing at it. Planning for the Most Difficult Exposure One thing that may help you confront your most feared situations is the combination of prescheduling of exposure tasks and adherence to the schedule from the beginning of treatment. In other words, when you are planning a program, make a schedule of when you will actually do the practices, then follow the schedule daily, with exceptions only for real emergencies. Procrastination is a form of avoidance and serves to maintain the OCD. Once you have learned the guidelines for exposure practice, you can set aside time each day when you will do your exposure practice. The sample schedule shown here can give you some ideas about how to make up a practice schedule for yourself. 76

85 Sample Practice Schedule Date Time What Practice You Will Do Wednesday 6 7 p.m. imaginal exposure: park bench Thursday 6 7 p.m. imaginal exposure: park bench Friday 6 7 p.m. imaginal exposure: park bench Saturday 9 10 a.m. imaginal exposure: park bench Saturday a.m. actual exposure: park benches Sunday 1 2:30 p.m. actual exposure: park benches Sunday 7 8 p.m. imaginal exposure: kitchen script Monday 6 7 p.m. imaginal exposure: kitchen script Tuesday 5 7 p.m. actual exposure: kitchen floor Notice that in the sample schedule only a couple of situations have been repeated. You don t have to confront all the situations on your schedule in the first week. In fact, it is good to begin by practicing one situation repeatedly until it gets a little easier, then add another situation to your practice schedule. Another thing to notice about the sample schedule is that at least an hour is scheduled for each practice. Because long exposure is more helpful than short exposure, it is good to try to schedule at least an hour at a time for your practice. One really important factor is to plan a schedule of practices and then to follow your schedule. Make yourself a schedule for your first week of self-exposure exercises. You should make up a new schedule each week, based on what you have already accomplished, what you d like to accomplish, and what you think you will be able to do. The length of your exposure exercise will depend on how much time you have and on how long it takes to experience some decrease in discomfort. Remember, it is good to keep practicing the exposure for as long as it takes to experience a noticeable decrease in your discomfort in the situation. This could take minutes or hours, depending on the individual and the situation. 77

86 What Is Courage? Often people think that exposure therapy is training to appreciate the benefit of courage. Courage is willingness to take necessary action in the face of fear. So there cannot be courage without fear. The patient who agrees to a necessary surgery knowing that it will cause quite a lot of pain and distress is showing courage. The Coast Guard rescuers who anxiously sail into a hurricane to search for a boat lost at sea are showing courage. You can probably think of many other examples of courage. Exposure exercises for OCD are exercises in courage. Risk Taking Sometimes a person will hesitate to confront a feared situation that is required for the program because the individual does not want to take a risk. Some people with OCD insist on absolute guarantees that things will work out all right before they will act. They are not willing to take a chance. Unfortunately, there really are no absolute guarantees, and trying to get them before acting leads to paralysis and exhaustion. Suppose you were a farmer who was concerned about flooding from a nearby river, because a flood could damage your crops and cause you financial problems. In order to be safe, you spend 2 months digging a ditch between the river and your fields, so that a river flood flows into the ditch and around your farm. You still feel that your fields are not absolutely safe, and even though you have not planted any crops because you were busy with the ditch, you decide to build a wall between the ditch and your fields just in case the water overflows the ditch. You spend 3 months and much of your savings building the wall. You still do not feel safe, so you decide to build another ditch and wall on the other side of the wall. You still don t feel absolutely safe, so you install pumps in the ditch, just in case the water comes over the first wall. By the time you have built all the protections, the growing season has passed, and you have not planted crops. You cannot pay your debts and you lose the farm and starve during the winter. The point here is that even though there is a risk of flooding, there is a cost to protecting yourself. Sometimes people spend much more on protection than they can afford, and it defeats the original purpose. When you insist on taking every possible measure to be absolutely safe, you will not be able to do much else. The cost is extremely high. Most people choose to accept small risks because it is more practical than trying to eliminate all risks. Confronting the feared situations involves very small risk. They are what would generally be considered safe situations. However, they are not absolutely safe: There is no absolute guarantee of safety. You must decide to accept the small risk of the exposure practices, unless you are prepared to accept the very high cost of continued obsessive distress, avoidance, and rituals. It can be tempting to try to get someone to help you by arguing rationally with you about the nature of the risk of doing the exposure task. Experience shows 78

87 that this does not work very well. You have probably already had people tell you that your anxiety is not justified, but this has not shaken the OCD. The nature of OCD is such that good reasons do not help. Rather, it is doing the exposure exercise that helps. Therefore, you have to step out of the trap of working so hard to figure out the risk, and instead get on with your program of exposure practices. Introducing Intermediate Exercises If you have followed your plan closely but get stalled on a high-distress item on your schedule, it may help to develop an exercise that is of intermediate difficulty between the last practice you did and the one that is stalling progress. Getting used to the intermediate item may help you with the more difficult one. It is better to adjust your program a little than to stall and give up. However, don t be too quick to adjust your program in a way that puts off the harder exercises, because too much putting off can slow or even stop your progress. Coping With Problems Unrelated to Exposure Sometimes things happen in life that are very stressful in themselves, and although the distress does not come from your exposure program, it can interfere with it. For example, while you are in the middle of your program, you may become upset by a recent event (such as an argument with a friend or relative), by thoughts about the future (such as having to get a new job and live in a new place on your own), or other concerns. If you encounter a major stressor during your program, and the combined stress of doing the program and coping with the life crisis becomes too difficult for you, this could be a good enough reason to postpone doing your exposure practices until you have coped with the problem that has come up. Then, when you are calmer and have more time and energy to get back to your program, you can restart it. Ways to Address Slow Progress Sometimes progress is slower than you would hope for. One potential explanation for this is that, for one reason or another, you are doing too little practice. Here are some suggestions: 1. If you forget to do your practice, use counter forgetting devises, such as reminder notes, setting an alarm clock, being reminded by a friend or family member, scheduling homework at a regular time each day, etc. 2. If you are avoiding practice because of anxiety, remind yourself that it is important to work on the practice despite accompanying anxiety 79

88 or distress, and that the long-term payoff is relief from obsessivecompulsive symptoms. 3. If OCD perfectionism is involved, remind yourself to try to do practices imperfectly on purpose, without spending excessive time on them, as a way of beginning to practice new habits. If you do not overcome your difficulties by yourself, a therapist with expertise in exposure-based treatment might be able to point you in the right direction. 80

89 Chapter 7 Extending What You ve Learned to Everyday Life Once you have successfully confronted the various situations on your exposure list and feel less distressed about them, it will be important to put into practice what you ve learned about exposure. This means that you should make an effort to use in your everyday life what you have learned about how exposure works to reduce OCD patterns. One obvious way to extend your program is to keep practicing your exposure exercises for a while, even though the exposure practices don t bother you much anymore. The purpose of this is to help you overlearn or strengthen your new ways of doing things. Another way to extend your program is to try doing your exposure exercises in a lot of new situations that are slightly different from the ones you have already tried. For example, if you have tried buying and eating unwashed apples from one supermarket, you could extend your program by purposely going to two other supermarkets and an outdoor fruit stand or a farmers market. The idea is to practice the same exercise, buying and eating unwashed apples, in a wide variety of settings rather than just in one market. Another example would be contact with toilets. Suppose that you have done a good amount of exposure with your toilet at home or at a particular restaurant, and this has become much easier for you than before you began your program. Even though it has become easier, it would be a good idea for you to visit different stores, restaurants, airports, and other public facilities, so that you can extend what you have learned to a wide variety of situations and strengthen your new patterns. One way to select everyday situations for extending your exposure practice is to go back to your list of avoidances that troubled you before you started your program. Are there kinds of places you have generally avoided because of your OCD? To extend your exposure practice, make a point of going to as many of these kinds of places as you can practically find, not just to one of them. 81

90 Returning to a Practical Routine Another way of extending your program to everyday life is planning to return to normal routines. This applies not only to entering all kinds of situations that you once avoided because of OCD but also to substituting nonritualized patterns for what were previously debilitating rituals. Once your distress about the items on your list has been markedly reduced with exposure, you can adopt an attitude of less exaggerated approach. For example, suppose your exposure practice involved purposely making many mistakes in conversations, because you were obsessed with making mistakes. Your new attitude would be to let yourself make some small conversational mistakes each day, but not to spend several hours per day practicing making mistakes. In fact, this new attitude is very practical: Everyone makes some small speaking mistakes once in a while, and you should count on doing this. Another example of extending your program to everyday life involves hand washing. If you have refrained from all hand washing for extended periods of time during your program and now have few urges to ritualized washing, you can adopt a more ordinary washing pattern: It is permissible to wash your hands but only when there is noticeable soil on them. Are your hands blackened from newspaper ink? Have you been working in the garden soil or on a greasy automobile engine? Have you been kneading a sticky dough or shelling shrimp? Did you spill gasoline on your hands when filling your tank? Can you see, feel, or smell dirt on your hands without close inspection? If so, it is OK to wash your hands briefly. If not, don t wash at all. Without close inspection is important, because you cannot afford to turn routine inspection of your hands for soil into a perfectionistic checking ritual. Do You Need Guidelines for Everyday Practices? If you have a history of difficulty in making useful practical judgments about what is practical rather than ritualized behavior, it may be helpful to develop some guidelines that match your particular needs. Such rules can bear much of the burden of decision making about formerly problematic situations. For example, as mentioned above, if you have had trouble with hand washing, the following rule might be appropriate: Wash only when there is real soil present, i.e., soil that can be seen, felt, or smelled without close examination. Perhaps it has been so long since you did a particular thing in a practically useful way that you really don t know what to do. If you are at loss to develop a rule for your particular situation, consulting your therapist or a practicalminded friend could be helpful. 82

91 Chapter 18 Maintaining Your Gains Treatment by exposure and response prevention modifies your obsessivecompulsive habits and reduces your symptoms. However, OCD rarely disappears completely, even after a successful treatment. Indeed, after a period during which you are doing quite well, a stressful situation may arise that provokes anxiety and urges to ritualize. It is important for you to be aware that this could happen so that you can be prepared to cope with it in a way that maintains the gains you achieved here with the therapy. Maintaining your gains requires understanding how relapse occurs, continuing self-exposure, and planning for changes in lifestyle. Relapse generally does not occur all at once. Rather, it happens through many lapses which accumulate until the symptoms again interfere with daily functioning. It is important that you do not give in to temptations to avoid or ritualize by rationalizing that it is OK just this once. If a lapse does occur, it is important that you view it as a single incident without getting demoralized, and immediately do selfexposure exercises. Remember, one lapse does not constitute relapse. However, giving up on self-exposure and ritual prevention can lead to relapse. It is like dieting: One extra portion is not in itself so important, but giving up on the diet because a bad day occurred can lead to significant weight gain. The most important factor in the maintenance of your gains is that you be active in continuing to apply what you learned during this treatment. If you don t practice what you ve learned here, you ll forget how to cope with occasional obsessive intrusions and urges to ritualize. Consequently, when they come up some time in the future, you can fall back into the old habits of avoidance and ritualizing. In order to strengthen your newly learned patterns, you must continue to practice them. If you don t practice, you ll lose what you ve learned and won t be able to cope well with an obsessive intrusion when it arises. 83

92 Principles of Self-Exposure To prevent relapse through self-exposure, you can try to do the following: 1. Recognize when an obsessive intrusion occurs, using felt distress as a tell-tale signal. 2. Refocus on the task at hand, rather than doing a ritual, as a first step in coping with the intrusion. 3. If the distressing intrusion persists, entertain it in an exaggerated way until the associated distress decreases. 4. If a pattern of distressing intrusions arises, purposely and repeatedly confront situations that evoke the intrusions until the distress, frequency, and duration of the intrusions decreases markedly. Methods for Coping With Stress As mentioned above, emotional stressors in day-to-day life can prompt lapses into OCD patterns. It is not clear just how this works, but it is commonly understood that a person can do only so much, and becoming overloaded by stressors can distract you from things that you are trying to do. For example, if you are trying to maintain a target weight through a program of diet and exercise and you encounter a number of stressors, such as financial, family, or work problems, you might not keep up with your diet and exercise program. One thing that might be helpful in maintaining the gains you have made with your OCD program is to learn to recognize what situations are stressful for you and to identify your habitual methods of coping with those stressors. Developing a list of potentially problematic situations (e.g., extra household responsibilities, school or job performance demands, specific interpersonal conflicts) and planning in advance how you will cope with them might make them less stressful for you. If you can reduce the emotional load from these situations, you may be less likely to lapse into OCD patterns in response to such stressors. There are a variety of stress management techniques that have been studied and found helpful. Sometimes people receive group training in these techniques called anxiety management training. One of the techniques is learning to express yourself clearly and effectively in social situations. This is often called assertiveness and is taught by behavior therapists in assertiveness training programs. Another technique involves identifying habitual thinking patterns that leave you emotionally distressed and changing these patterns. This is called cognitive restructuring and is emphasized in cognitive therapy. Other techniques involve ways to relax yourself physically and mentally. These include progressive muscle relaxation and other meditation techniques. 84

93 This book is not designed to help you develop a general program of stress management. To help yourself improve your ways of managing stressors, you can learn some or all of these techniques, either by reading about them or getting coaching from a therapist who is expert in these particular methods. Informing Your Family and Friends It is often useful to inform your family and/or friends about what you have done in your program and what you are doing to maintain your gains so that they can support you in maintaining your gains. Of course, you will need to decide whether you want to talk about this to a particular person, and if so, just how much you want to say. Some people do not have the capacity to understand the nature of OCD and its treatment, and trying to get them to understand it in the way you understand it can be frustrating and unrewarding. If you do decide to tell individuals about your OCD and what you have been doing about it, you should try to match what you tell them to their capacity to understand. Most people can understand the idea of habits that are difficult to overcome, and this is one way to describe your experiences. Most people can also understand that different people have different weaknesses or vulnerabilities, and that you have a vulnerability to develop the pattern of anxiety, avoidance, and rituals. It can be more difficult for someone to understand how both medication and a cognitive-behavior therapy program can help with the OCD patterns. They often insist on knowing whether OCD is mental or physical. An overly simple but useful answer is that OCD is both mental and physical, and so each kind of treatment is often helpful. When you talk to family and friends about your situation, you can teach them that it requires extra effort on your part to handle stressors without lapsing into some OCD patterns. This includes interpersonal stressors. This means that it will not help you if family and friends are in the habit of criticizing you about your OCD symptoms. Having completed your program, you already know that your OCD symptoms are trouble. Also, you can teach them not to worry very much about occasional lapses that you may have. As long as you recognize lapses for what they are and react to them by doing some exposure practice, the lapses will probably not turn into relapse. Finding New Activities to Fill the Space Left by OCD For some individuals, obsessions, avoidance, and rituals have occupied so much energy for such a long time that they got in the way of developing other interests. If this has happened to you, it will be important for you to develop some interests 85

94 in things that you can do to occupy time formerly spent on obsessions and rituals. Unless you find things to do that genuinely interest and satisfy you, you will be tempted to fall back into doing what you already know too well how to do: obsess and ritualize. If you are sitting at home all day, most days, bored and aimless, obsessions and urges to ritualize are likely to intrude. To help you maintain your gains from your exposure program, you should find something engaging to do. If you are unskilled or disorganized in developing new interests and activities and have trouble finding things that interest you, you might seek help with this from family and friends or from a vocational guidance counselor or therapist. 86

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96 For more information on Graywind Publications or TherapyWorks products, please contact The Psychological Corporation at (TDD ).