Comprehensive Treatment for Primarily Obsessional OCD
By Dr. Christian R. Komor
OCD Recovery Center
Part 3: Obsession Innoculation (Cognitive and Pysiologic Approaches)
- Attention Training (ATT). Attention Training is the primary tool used at the OCD Recovery Center for assisting OC sufferers in detaching from obsessive thoughts and reducing overvalued ideation. ATT was developed by British researcher Adrian Wells and involves placing repetitive sound sources (television tuned to static, radio, fan motor) at similar sound levels in all four corners of a room. The individual focuses their vision on a spot in front of them and shifts their hearing only from one sound to another in a randomized fashion gradually increasing the speed of the shifts from one sound to the next. This technique, very similar to meditation, not only strengthens the individual's ability to selectively focus attention, but also seems to "cool down" the obsessional part of the brain by "heating up" competing areas. Like Massed Exposure, ATT must be practiced daily in order for it to achieve an effect.
- Meditation is an alternative for those who do not benefit from, or dislike Attention Training. Meditation in its many forms provides a time-tested vehicle for strengthening the mind. The stronger and more trained an individual's mind becomes, the better they are able to dismiss and separate their awareness and self-identity from obsessive thoughts. Meditation helps the individual to see that obsessive thoughts are unimportant and instead, visualize the obsession like a small cloud - notice it and then let it drift away. Realizing that obsessions are of no real consequence helps to see them are "just brain noise" - the result of disordered impulses coming form the brain.
- Maintaining a healthy stress/relaxation balance is critical in recovery from O-OCD. OC sufferers continually report that increased levels of stress cause increases in obsessions. Likewise, having nothing to do also seems to stimulate obsessions for many people. Balance seems to be the key.
- Yoga Breathing. Researchers at UCLA developed and test a yoga breathing technique which reportedly reduced some forms of OCD by 70% or more. The technique involves closing off the right nostril and breathing through the left (both inhalation and exhalation) for approximately 30 minutes per day. The positive effects were seen over six to twelve months of daily practice. Unlike ATT and ME this technique can be done while doing other activities such as watching television or riding in the car.
- Centering. The primary skill needed to transcend obsessions is to shift the individual's focus inward (through centering, physical techniques, etc.) and then actively relax. "Centering" is an excellent mind-body tool for keeping the focus on ourselves and not projecting. Centering involves focusing attention on the geographic center of the physical body - known as the "hara" in Japan. (Additional Centering suggestions are included in next section.)
- View anxiety as the fuel that causes obsessions to appear. Developing active methods for anxiety reduction tends to reduce obsession. The OCD Recovery Center offers several handouts on this subject.
- It is essential for the individual to simply feel the anxiety that comes up when one are confronting an obsession. This is very important. If one does not give in to an obsessive thought the anxiety connected to that thought is almost certain to rise. This is normal. The simple but extremely difficult task is to watch the anxiety and allow it to be there. It will gradually drop time (How much time varies widely from minutes to months!) and this is how real positive brain change happens. Remember, those with OCD are confronted with two choices: Feel the anxiety and refuse to ritualize and perform compulsions or feel the anxiety and give in to what the OCD is asking one to do. Either way there is anxiety. In the former there is anxiety that leads to eventual recovery. In the latter there is anxiety, relieved by compulsion - leading to further enslavement by the OCD. OCD can be thought of as a blackmailer that is never satisfied.
- Attempting to suppress thoughts almost always has the opposite of the intended effect - making them stronger still. Thought stopping in all it's various forms (e.g. rubber band snap on the wrist), while helpful for other situations is likely to make obsessions worse for this reason.
- Likewise, for another person to try to point out the unrealistic nature of an OC sufferer's obsessions is at the least unhelpful and at worst will strengthen the obsession. Obsessions by their very nature do not make sense in the same way that an epileptic seizure does not make sense. It is simply a brain dysfunction - a random spike of energy or "short circuit".
- Learning to tolerate the unwanted thoughts and not avoid or escape them - however that is accomplished in a particular situation or setting - is the antidote to O-OCD.
- For Intrusive Obsessions creating brief exposures (e.g. turning off and on the part of a song that gets stuck in the individual's mind) may be helpful.
- Neurofeedback is another emerging tool for confronting obsessions. Neurofeedback is done with a highly trained psychologist who first makes a "brain map" of the individual using computerized electroencephalograph equipment. The individual is then given a video game to play using their mind. In order to make the game operate the individual must achieve the desired brain state (e.g. non-obsessional, low-anxiety, etc.).
- The One-Second Rule. If the individual is tempted to obsess about a body sensation, thought, or other item they can be instructed to allow themselves only one second to think about it. Then they redirect attention to something closely related (e.g. another body sensation). Finally, they redirect attention to something else they would like to do or think about. (This is sometimes called "selective attention".)
- Obsessions are "projections" of our self into the past, the future, other people, etc. Focusing on the present and what the individual is doing right this moment diminishes the hold obsessions have.
- Humor. Is very important in obsession recovery. OCD wants the sufferer to take it seriously. Finding ways to make fun of the obsession ("And now Dr. Evil is going to kill.")
- Focusing the mind on positive circumstances or behaviors rather than the obsessions or what might be "wrong" tends to decrease some obsessions. A good way of doing this is by making a "gratitude list" at the end of each day - listing what one is grateful for in their life.
- Encourage a "Just be and don't think" attitude on a continual basis. Obsessions live in the mind. Redirecting the attention always back on experience versus thoughts helps calm down obsessions.
- Shadowing. Following someone the individual trusts through a behavior that has been difficult due to obsessing can help to break the obsessive routine or rut.
- Obsession Box. Place a copy of the Serenity Prayer on a box or bag. The individual can then write down an obsession, place it in the box, then let it go mentally. If they begin to worry about it again they can remind themselves to "put it away".
- Thought Backtracking. Instruct the individual to notice when an obsessive train of thought begins - then think of the thought like a train and reverse the direction. What was the thought they had before the current one? What was the one before that? What was the initial thought ("engine") that started off the thought train? When the sufferer arrives back to the original thought - almost always something involving the material world, five senses and real, present-time experience, instruct them to stop and focus on enjoying that. Note that Thought Backtracking is different than what is known as Thought Stopping - which does not generally work for OCD.
- Catharsis can be illusion. One of the difficulties for individuals with obsessional thinking is that it is difficult to trust one's own ideas and feelings. Many times it becomes important to set limits on "self-exploration" (e.g. delving into childhood trauma) because the obsessive ideation is distorting the situation out of proportion. Usually it is best to stay in the here and now and deal with the obsessions. At least by doing this first one can say, "If I get past these obsessions and I still have issues about the past or certain people then I can focus on that line of inquiry." If the obsessions are being powered by blocked emotions - especially from traumatic life experiences the individual can find a safe way to feel and express feelings (tears, anger, fear, grief, etc.). A technique called Eye Movement Desensitization and Reprocessing (EMDR) works well for this purpose (although people with OCD often respond differently to EMDR than other subjects). For people with OCD feelings can be more of an illusion than an answer.
- Slow Motion Focus. If the individual tends to become stuck in a particular behavior it may be helpful to try going very, very slowly through the behavior. For example: Put in the key...wait...turn the key...wait...pull the key out...wait...turn the knob slowly...wait...open the door slowly.
- If the individual is having trouble getting free of an obsession, try having them try changing the setting. Suggest a day off to go to the beach, grandparents, visiting friends, hiking, etc. They can take note of positive changes experienced and take these experiential learning's back to the regular routine.
- To combat obsessions it is helpful to take some time each day to practice "Non-doing".
- This means just sitting without any purpose or activity and working to just be aware of sitting and experiencing the environment with the individuals five senses.
- Saying "No" to shoulds tends to lead away from obsessions. Giving ourselves freedom of choice and the ability to listen to our own desires is the opposite of obsessing. Encourage this in the individual's daily routine.
- Sometimes obsessions can be the result of difficulties with memory (e.g. obsessing about what signs say, or if the stove is turned off). Explore if this might be the case for the individual. If so, develop memory tools to assist the individual.
- Ritual Delay. This involves delaying acting out a compulsion, which will reduce the individuals anxiety about an obsession. For example, waiting 60 minutes and then asking the individual if they need to do the neutralizing ritual or if the obsession is "just brain noise" to be ignored.
- Have the individual keep in mind the idea of an "Obsession Pie". Visualize a pie with a very small slice darkened in. This slice represents the reality of the individuals worries - most worries have at least some basis in reality. The rest of the pie represents obsession. Our job is to reduce the obsession part of the pie.
- Ah... Every word the human race has created for God has the sound "ah" in it. Making this sound creates a pleasant and anxiety reducing vibration in the body. The next time the individual finds themselves obsessing have them try making the sound "ah..." for five or ten minutes and see if it doesn't shift their focus to more pleasant and rewarding experiences.
- Compulsion Substitution. In an emergency, instead of the individuals usual obsession try substituting tapping gently three times on the head. Let this satisfy the OCD for the time being until other tools for recovery can be developed. Keep in mind that compulsion substitution will probably encourage the obsessions when used.
- Help the individual to find their "want to". Free will and choice are the enemies of compulsion and obsession. Try asking the individual here and now in this moment what they want to do or say. This may be very scary since they are used to doing what the OCD tells them they "should" do. When the individual gets the hang of it, though, it can be very freeing!
- Encourage a sympathetic self-view. Having an obsessive-compulsive disorder is difficult, stressful and time consuming. Remind the individual not to expect themselves to be able to accomplish what they could if they did not have a disability. Encourage them to be understanding and to take it easy on themselves.
- The Head Shake Technique. If the individual finds themselves obsessing suggest they simply shake their head as if shaking the thought right out of their head.
- Rubber Band Technique. Place a rubber band on the individual's wrist and have them snap it when the individual notices them self-obsessing.
- Encourage the individual to keep in mind some helpful slogans and reminders such as: "Relax." "De-escalate." "Disinhibit." "Be spontaneous." "Detach." "Let go." "Accept." "It's ok to have things be imperfect." "Lighten up!" Say "So what!". "Live in the now."
- The oriental practice of Qigong is very helpful in reducing the anxiety and providing a healthy activity to do while experiencing the anxiety related to ERP work. The OCD Recovery Center can provide training in basic Qigong, or direction to a practitioner or video training series.
- Finally, be aware of the possibility of "neutralization obsessions" which involve the replaying in the individual's mind of an anxiety producing event. Although this may look like obsessing is can actually be a form of self-stimulation in which the individual replays an event or circumstance, perhaps to "get it right". Instead of confronting anxiety this leads to a perpetuation of the anxiety. Instead of traditional ERP neutralization obsessions call for a "letting go" approach in which the they are encouraged to simply let the thoughts flow through them without hindrance.
Part 4: Centering: A Novel Anti-Obsessional Agent >>