jon hershfield - mind washing: mastering the unique challenges of metal rituals

MIND WASHING: MASTERING THE UNIQUE CHALLENGES OF MENTAL

RITUALSJon Hershfield, MFT

Monnica Williams, Ph.D.Elspeth Bell, Ph.D.

Jeff Bell

The 23nd Annual IOCDF ConferenceChicago, IL July 29th 2016

Why this talk?

• OCD sufferers often unaware of role of mental rituals or unable to articulate experience of them

• Clinicians often misdiagnose OCD as GAD or other disorders

• Both need a language for assessing and treating OCD in the absence of overt observable rituals

OCD BASICS• Obsessions – unwanted intrusive thoughts

that are associated with discomfort, often repetitive, typically ego dystonic

• Compulsions – physical OR mental behaviors engaged in for the purpose of seeking certainty and relieving discomfort associated with obsessions

But the DSM says…• Presence of obsessions OR compulsions.• But really people with OCD have

obsessions AND compulsions (Williams

et al., 2011; Leonard & Riemann, 2012).

• You just have to be able to identify the compulsions!

“PURE O” OCD• Misnomer used to identify sufferers whose

compulsions are primarily mental or covert• Term “pure obsessional” showed up in early 90’s,

then replaced with “primarily obsessional”• Is not a clinical reality or separate diagnosis from

OCD• Label used by sufferers for fostering sense of

community

Rates of Covert Compulsions by Primary Obsession Type

OBSESSIONS

• All obsessions involve mental rituals, though some are more commonly associated with “pure o” or invisible compulsions

OBSESSIONS• Contamination obsessions may involve

physically washing, cleaning, and avoiding, but also involve significant mental rituals

• Responsibility obsessions may involve repeating and checking, but also involve significant mental rituals

COMMONLY ASSOCIATED WITH SIGNIFICANT MENTAL RITUALS

• Harm OCD – obsessive thoughts of aggression, fear of acting out violence impulsively or self-inflicting harm


• Sexual Orientation OCD (a.k.a. HOCD) – fear of “turning into” or being in denial of other-orientation identity


• Pedophile OCD (a.k.a. POCD) – fear of being sexually attracted to children or impulsively acting out sexually with children


• Relationship OCD (a.k.a. ROCD) – fear of inadequacy or dysfunction in romantic relationship


• Scrupulosity – religious or moral rigidity, fear of being disconnected from faith, blaspheming, or being morally inadequate


• Hyper-awareness obsessions – discomfort associated with awareness of involuntary processes (i.e. blinking, breathing, swallowing, or thought process)

MENTAL RITUALS

• Thoughts as contaminants of the mind

• Some people wash their hands, some people wash their minds

MENTAL RITUALS• Covert compulsions• Often un-noticed by others• Often overlooked by treatment

providers• Sufferer may be unaware or believe

mental behavior to be non-compulsive

MENTAL REVIEW• Mental review is occurring when a person is examining a

past experience repeatedly for the purpose of letting it go. This is sometimes referred to as “rewinding the tape” because it is the mental equivalent of studying a scene over and over. Since the sufferer believes that reviewing the event (interaction, conversation, statement, etc) will result in resolving it and subsequently reducing uncomfortable thoughts and feelings, it is a compulsion.

MENTAL REVIEW• Often confused with “just working it

out” or honest attempt to gain insight into or understand meaning of obsession

• Interchangeable terms - retracing, replaying, rewinding, ruminating

MENTAL CHECKING• “Digging up” a thought for the purpose of

engaging in mental review. This also occurs when a sufferer becomes aware of an obsession being absent. They then mentally “check” to see if the thought still bothers them and compulsively test it to see if it is truly resolved. This is essentially bringing on an obsession to prove it has gone away.

MENTAL CHECKING• Can also be applied to feelings and

bodily sensations, such as in checking one’s groinal response to a sexual obsession. This includes mentally investigating the potential source of a thought or feeling to determine why it occurred.

SCENARIO BENDING• Hypothesizing, theorizing, exploration of what WOULD happen• This mental ritual combines review and checking by first

replaying an event that did take place, and then adding a hypothetical element of the event that could have but did not

take place. Someone engaging in this compulsion would then proceed to analyze how they would have behaved if the feared scenario did take place. The ritual is aimed at determining how appropriately one would respond in a feared hypothetical scenario in the hopes that they will have certainty of their moral constitution.

REVERSE RUMINATING• Mental rehearsal• While mental review often involves replaying the past, “reverse

ruminating” involves playing back invented ideas of the future in an attempt to check for likelihood of catastrophe. Unlike scenario bending, which starts with a real event, reverse ruminating takes place entirely in the future, at an upcoming performance, encounter, interview or some other future event that could go terribly wrong.

• often confused with simply preparing, but it is better described as compulsively going over and over something that has yet to happen in an attempt to relieve discomfort about what could happen.

THOUGHT NEUTRALIZATION

• This is a mental behavior centered around silently saying words or attending to thoughts that are the opposite of the unwanted ocd thoughts. The belief is that a “good” thought will neutralize a “bad” one and preempt unwanted consequences.

• Can include intentional focus on opposite feelings to neutralize intruding ones.

SELF-REASSURANCE• Many OCD sufferers ask people close to them to help them

attain a sense of certainty about an obsession. They may also do this through compulsive research on the internet or elsewhere.

• Self-reassurance comes in the form of mentally repeating reassuring statements to gain a sense of certainty that the unwanted consequences of a thought will not occur. Often times this is a ritualized version of positive affirmations.

• May involve mental review of previously acquired reassurance.

SELF-REASSURANCE• Contingency planning – reviewing fantasy scenarios in which the feared consequences are coped with or neutralized (e.g. repeatedly telling yourself you’ll escape to Argentina to avoid prosecution for a feared crime)

• Suicide fantasies – function as a wishing ritual, imagining a space in which the thought ceases to be present or as a contingency plan (see above). Must be distinguished from actual ideation or intent.

• Celebrating – Excessively focusing on moments wherein the unwanted thoughts are absent, self-reassuring that they are really gone and not coming back.

COMPULSIVE FLOODING/TESTING

• As a behavioral technique, flooding can be an effective form of short-term exposure with response prevention for an unwanted thought. It would typically take the shape of agreeing with and exaggerating the thought until habituated.

• May be distorted into a form of testing reactions to situations by forcing unwanted thoughts in specific circumstances. Because it is painful, it demonstrates that the thoughts are ego dystonic and this functions as a form of self-reassurance (this is very prevalent in sexual and harm obsessions).

COMPULSIVE FLOODING/TESTING

• Can be associated with “backdoor spikes” in which sufferer is concerned that they are not as anxious about a thought as the “should” be.

• Often goes un-noticed by treatment providers but causes unnecessary suffering with no habituating payoff

• Sufferer unlikely to even mention it as a compulsion because it is painful, overlooking that it is still a form of checking and avoiding discomfort with uncertainty

SELF-PUNISHMENT• The sufferer believes they have done something wrong or committed some sort of unforgiveable error. To accept that sometimes they do the wrong thing and move on would mean tolerating the discomfort of feeling like they were getting away with a crime. To account for this, they may intentionally force feelings of guilt and negative self-thoughts as a form of sentencing for their crime. Once they have been adequately punished, they are more likely to feel able to move on.

SELF-PUNISHMENT• While this is obviously unpleasant, it is nonetheless

compulsive because it serves to avoid the discomfort of feeling like they have escaped justice.

• Often overlooked as simply a product of perfectionism and low self-esteem.

• Important to address as a voluntary behavior, separate from the intrusive negative self-thoughts or cognitive distortions.

MEMORY HOARDING• As in physical hoarding, the OCD sufferer engaging in

this compulsion is going out of their way to save small bits of information for potential recall. This often occurs at the sacrifice of staying in the moment or enjoying anything for fear of missing out on carefully storing an event in memory.

• Examples of this may involve compulsively memorizing interactions with people or actively attending to memorization of the details of a room or a book.

COMPULSIVE PRAYER• For scrupulosity sufferers, prayer is often used to

counteract the intrusion of anti-religious or otherwise unacceptable thoughts. Prayer becomes ritual when it is used repeatedly to neutralize thoughts or evade them, rather than as an attempt to more genuinely connect with one’s religious faith.

• May also be engaged in as a form of thought neutralization even when obsession is non-religious in content.

COUNTING• The mental behavior of counting in a mathematical

pattern or of counting steps, objects, lines, etc. can come in two forms.

• It can be its own compulsion, in which the OCD sufferer feels the need to count to keep something bad from happening

• or it can be used as a form of compulsive avoidance by counting instead of allowing other unwanted thoughts to stay present.

MATHEMATICS• Mentally reviewing the number of times an event

occurred and/or the dates of events in an attempt to determine the severity of an event and self-reassure.

• For example, someone obsessing about their sexual past may attempt to form in their mind a statistical average of sexual partners over time in an attempt to feel certain that they have not been promiscuous.

MENTAL CHANTING• Mentally repeating words or phrases, whether

positive, neutral, or upsetting, by rote. • May be done a certain number of times or

until a desired feeling or mood is established. • Must be intentional and distinguished from

intrusive uncontrolled repetition of thoughts.

TREATMENT CONSIDERATIONS

• MINDFULNESS• COGNITIVE RESTRUCTURING• EXPOSURE WITH RESPONSE

PREVENTION

MINDFULNESS• Acceptance of presence of thoughts, feelings, and

physical sensations without judgment• Developing skill of acknowledging and walking away

from mental rituals and toward the present• Noticing urge to ritualize and accepting as part of

present state without responding• Using meditation and “mindfulness in the moment” as

practice• “Noting” as a strategy for reducing mental ritual• Purpose: increase awareness of when distracted and

return to present moment without further analysis

Cognitive Restructuring• Identifying and challenging cognitive distortions –

patterns of thinking that promote ritualizing (i.e. all-or-nothing, catastrophizing, emotional/magical reasoning)

• Not about disproving fears, but about disengaging from “need” to ritualize by acknowledging uncertainty

• Important to keep brief and secondary in order to avoid becoming a self-reassurance ritual

• Watch for “rationalizing”• Positioning self as observer of thought process

EXPOSURE WITH RESPONSE PREVENTION (ERP)

• Essential for all forms of OCD• Include imaginal exposures (a.k.a. scripting) when in

vivo unrealistic (may be more effective to use fresh-written scripts to avoid mental rituals instead of loop tapes or repetitive reading scripts)

• Goal of triggering urge to ritualize for the purpose of habituation and development of resistance skills

HAVING THOUGHTS VS THINKING

• Having thoughts – the uncontrollable appearance of an idea (thought, feeling, sensation)

• Thinking – the voluntary behavior of analyzing an idea (thought, feeling, sensation)

BACKGROUND NOISE

• Some mental rituals may become an automatic thought process that continues despite treatment

• Focus on controlling the controllable and accepting the uncontrollable

LABEL AND ABANDON• Core concept of addressing mental rituals is to educate

sufferer to identify and label mental ritual as a behavior, then abandon before completion (“OK, I’m reviewing, don’t need to do this right now, walking away”)

• Expected consequence is feeling of incompleteness and irresponsibility

• Goal is to catch and release sooner and with less effort• NOT thought-stopping… ritual stopping!

Distraction• Can be used compulsively or as a tool for

interfering in mental rituals• Purposely interfering in ability to think by

confusing self during mental ritual with competition – e.g. remembering lyrics to a song or the sound of a 56k modem

Novel ERP Games• Grand Theft Auto at the Mall ERP (purposely

opening up to all obsessive thoughts in a public space without engaging in mental rituals)

• Exercise, The Exercise (purposely exposing to obsessive thoughts during first half of an activity, then employing distraction in second half)

FINAL THOUGHTS• Therapists treating OCD must consider all rituals, not

just physical ones. Even when physical rituals are properly addressed, sufferer may sublimate them with mental ones and remain similarly impaired.

• Sometimes helpful to frame course of CBT as getting the physical compulsions ceased and out of the way for the purpose of addressing the mental ones that bolster the obsession.

FINAL THOUGHTS• Sufferers benefit from understanding mental

rituals as compulsions, a behavioral aspect of obsessive compulsive disorder and not a separate issue or diagnosis

• There is no “PURE O” beyond the name and obsessions with primarily mental rituals are equally treatable with CBT

references• Williams, M. T., Farris, S. G., Turkheimer, E., Pinto, A.,

Ozanick, K., Franklin, M. E., Simpson, H. B., Liebowitz, M., & Foa, E. B. (2011). The Myth of the Pure Obsessional Type in Obsessive-Compulsive Disorder. Depression & Anxiety, 28, 6, 495-500.

• Leonard, R.C. & Riemann, B.C. The co-occurrence of obsessions and compulsions in OCD. Journal of Obsessive-Compulsive and Related Disorders 2012;1:211-5.

contacts• Jon Hershfield, MFT

– ocdbaltimore.com, [email protected]

• Monnica Williams, Ph.D.– https://louisville.edu/psychology/williams,

[email protected]

• Elspeth Bell, Ph.D.– Elspethbellphd.com, [email protected]

• Jeff Bell– Beyondthedoubt.com, [email protected]

jon hershfield - mind washing: mastering the unique challenges of metal rituals

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