Family Accommodation: What do I do instead?
Family Accommodation is when family members or significant others participate in or facilitate their loved one’s compulsions and/or avoidance. Examples of Family Accommodation...
Family Accommodation is when family members or significant others participate in or facilitate their loved one’s compulsions and/or avoidance. Examples of Family Accommodation...
Shame is such an important topic when talking about OCD. Most people I see in treatment have already overcome one hurdle of shame just by reaching out...
I think most people would be surprised to learn that ERP can actually be a lot of fun. Hear me out - I know ERP tends to get a bad rap. We’re asking people to face their fears...
“Those who are hardest to love need it the most” was first said by Socrates, and it applies quite well to the concept of self-compassion. Those who are the hardest...
Obsessive compulsive disorder (OCD) involves the triggering of unwanted thoughts, images, or impulses (i.e., obsessions) that provoke feelings of...
Shame is such an important topic when talking about OCD. Most people I see in treatment have already overcome one hurdle of shame just by reaching out and asking for help. Even so, they are often still experiencing a tremendous amount of shame, whether that be general shame, shame about having a mental illness, or more symptom-specific shame (e.g., what will my therapist think if I tell her I have intrusive thoughts about losing control and masturbating in public?!), which is common in folks with sexual and harm obsessions. Before diving further into talking about shame, we need to first understand a little bit about shame’s close cousin, guilt, because there’s some confusion about how these two emotions are different. We often talk about guilt and shame as though they’re interchangeable, but guilt is really the emotion we feel when we believe we’ve done something wrong. When we make an insensitive comment to our friend or partner, we might feel guilty once we realize we’ve hurt someone else’s feelings. Guilt can be healthy in situations when we’ve actually done something wrong. It gives us the opportunity to reflect back on our behavior and decide to offer an apology. It’s important though that we keep the level of guilt in proportion to the behavior. Feeling excessively guilty about perceived harms we’ve caused (e.g., feeling immense guilt the entire afternoon because we accidentally interrupted our coworker during a meeting) can be problematic. When the level of guilt becomes excessive, it can lead to repeatedly apologizing, seeking reassurance about the relationship, ruminating, overanalyzing the situation, as well as other compulsions. Sometimes it can also lead us into shame territory. Like guilt, shame can sometimes be triggered by thinking we’ve done something bad, wrong, or hurtful. With shame though, there’s an added layer of thought. We’ve progressed from “I did something bad” to “I AM bad because of something I did.” Now we’re questioning our very worth as a human being. Shame is a common emotion that almost all human beings have felt at one point or another. Most of us can identify with making a mistake and then thinking to ourselves “I’m such an idiot. I can’t believe I did that.” I’m not endorsing that line of thinking – just acknowledging that we’ve all been there. Calling yourself an “idiot” or any other name is basically saying there’s something intrinsically wrong with me, which is the same as saying “I’m bad.” It’s also incredibly common for people with OCD to experience shame about their symptoms. I’ve heard people with contamination fears who have elaborate shower routines tell me how “crazy” they are for having these fears – and “crazy” is another stand in term for “bad”. Or people with relationship OCD, who have experienced multiple relationships crumbling because their partner grew tired of their accusations of cheating or could no longer tolerate their excessive reassurance seeking, feel shame over their compulsions and internalize thoughts of “I am broken” or “I am needy.” And folks with violent, sexual, or religious obsessions often feel immense shame directly linked to the content of their OCD thoughts. They have an intrusive thought, for example, about molesting their baby when they change their diaper, and then they interpret that thought as saying something about them as a person, so they struggle with thoughts of being a “monster” or “dangerous.” They may wonder what others would think of them if they knew what was going on in their minds. Unlike guilt, shame really has no adaptive purpose. In fact, research has found that shame has a negative and damaging effect on interpersonal relationships, and it is linked to social withdrawal, depression, and suicide. Shame also tends to be a barrier for people seeking out treatment due to worry over being judged negatively or harshly. So where does shame come from, and what can we do about it? There’s no straightforward answer to the question of where shame originates. It can be different for everyone. No doubt, we’ve all had experiences throughout our lives that have reinforced shame to different degrees. It could come from messages we hear from family members, peers, the media, really anywhere. Certainly traumatic experiences can induce shame. Maybe what’s more important to understand about shame is how it is fueled. If we can understand what maintains it, then we can generate ideas about where and how to intervene in the present.
“Those who are hardest to love need it the most” was first said by Socrates, and it applies quite well to the concept of self-compassion. Those who are the hardest on themselves are the most in need of self-compassion, aka self-love. I’ve also noticed that those who are the hardest on themselves are generally the most resistant to the idea of practicing self-compassion. For some people, just the suggestion of learning about self-compassion elicits eye rolling. I have to admit, when I first learned about self-compassion myself, I wasn’t entirely on board. However, the longer I’ve been a therapist, the more I see the deep need for increased self-compassion in my clients, and in myself. The first step of self-compassion is noticing your own suffering. This means resisting the urge to put on a brave face and pretend like everything is okay and instead allowing yourself to be affected by your struggle. It could be as simple as acknowledging “I’m having a really hard time" and allowing that to sink in for a moment. Then the second step is offering yourself kindness and caring. This could translate into allowing your body to rest if it’s tired or engaging in an enjoyable hobby, but it could also mean pushing yourself to do some chores before having fun. The key here is whatever you do, you must do it without judging yourself harshly. Imagine the way you’d speak to a young child (or maybe the way you wish you’d been spoken to as a young child). If that doesn’t feel right, maybe think of how you would talk to one of your pets. Use a gentle voice and a caring attitude. Consider what it is that you in need in this moment and then give it to yourself. Another important component of self-compassion is the recognition that we’re all imperfect – it’s just part of being a human being. This part is actually my favorite part, and I think it’s so powerful if you really think about what it means. Rather than using our imperfections to berate ourselves in times of struggle, we can use them to feel a little less isolated! Yes, I am imperfect because I’m a human being, but that also means that everyone I know, and everyone I don’t know, is also imperfect. They (we) also struggle with things – many of the same things actually. So the idea is that our imperfections are actually part of a shared experience that can bring us closer to one another, as opposed to setting us apart. How does all of this relate to OCD though? Well, it turns out that people with OCD tend to have lower self-compassion, and interventions that help to increase self-compassion help to improve treatment outcomes. Self-compassion can also go a long way to decreasing shame since shame is all about secrecy and harsh judgment. So think about how you talk to yourself when you have an intrusive thought or image you don't want. Do you berate yourself for not being able to control your thoughts? Or do you acknowledge that it's hard dealing with intrusive thoughts and remind yourself you're doing the best you can? What about when you get caught in a loop of doing compulsions for several hours? Do you tell yourself that you're the only one who has to deal with things like this? Or do you remind yourself that everyone struggles with something and that's just part of being a human? Return to top of page
I think most people would be surprised to learn that ERP can actually be a lot of fun. Hear me out - I know ERP tends to get a bad rap. We’re asking people to face their fears, and on the surface that certainly doesn’t sound like a lot of fun. Even some (non-ERP) therapists have a negative reaction to the idea of exposure therapy. But in my experience, people who have negative feelings about exposure therapy are generally people who don’t know much about it. A large number of my friends and colleagues practice ERP, and I think they’d agree with my assessment that ERP can be fun. Now, to be very clear, I don’t think there’s anything fun or funny about having OCD. I have a lot of compassion for people who are struggling with OCD. From my perspective, most people are entering into OCD treatment with a lot of heaviness surrounding their symptoms - meaning when they think about their intrusive thoughts and their compulsions, they feel all kinds of negative emotions like anxiety, disgust, fear, shame, and sadness. There’s certainly nothing light or uplifting about the way people describe their OCD symptoms. But if that’s how OCD feels, shouldn’t OCD treatment feel very differently? I think it should, so here are some of the ways it can be helpful to add some laughter and silliness to ERP. Treatment is hard, and sometimes people dread coming to session. I’ve had people tell me “No offense, but I didn’t want to come to session today.” What they mean is that they know we’re going to do exposures in our sessions and a part of them doesn’t want to. That’s normal! If you’re doing ERP right, it’s going to be emotionally challenging. Hopefully, you end your sessions feeling like you’ve accomplished something, but that doesn’t necessarily mean you’re going to look forward to each session. So having some laughter infused into treatment can help keep things from being so terribly heavy and might give you something to look forward to. Another reason to use laughter in ERP is that it helps you detach from your obsessions. A key component of ERP is learning to objectify your thoughts - meaning you learn to view them as separate from yourself. This generally helps people get some distance from their thoughts, which makes it easier not to automatically respond to them. It can also reduce the shame around certain obsessions. There are many ways to encourage detachment from obsessions, but laughter is the most fun. Try it! Choose one of your obsessions - this works especially well for harm, sexual, or religious obsessions - and say it aloud. Now say it aloud using a Mickey Mouse voice, or a British accent (unless you’re British - then pick something else). You can use this to “mess up” mental/verbal rituals too. If one of your compulsions is to think/say a prayer or repeat a mantra, try doing it with your best Darth Vader impression. OCD has no sense of humor, and it absolutely thrives on rigidity and predictability. Anything you can do to challenge that is good for you and bad for OCD. How else can laughter be helpful in ERP? Well, maybe it can help you feel less alone? There’s something about sharing a laugh with another person that brings people closer together and reminds us how connected we are. Some of my favorite (and I think most therapeutic) moments have happened in the midst of laughter. I remember many years ago doing a contamination exposure with one of my clients. We were sitting in a bathroom eating crackers directly off the tile floor. At first, my client was visibly anxious because he was concerned about getting sick, but we sat there for a while just eating cracker after cracker until he began to feel calmer. And then we looked at each other…and looked at the crackers…and then looked back at each other, and then we both just started laughing hysterically. There was something about the overall ridiculousness of the situation that hit both of us at the same time, and we thought it was hilarious. I really think something healing happened in that moment, as odd as that might sound. We just became two people sharing a silly moment, and aren’t those always the best moments? I talk a lot about shame because I know it’s something most of my clients struggle with. For me, being able to laugh with someone about their OCD symptoms seems to help decrease that shame, so I’m all for it. I do want to caution against using laughter as a distraction technique or as a way to avoid feeling uncomfortable feelings. That’s not what I’m talking about here. During exposures, we need to focus on the discomfort and not try to make it go away by cracking jokes or making light of things. But it’s also not all or nothing. Even alongside high quality exposure therapy, I think there’s room for some irreverent humor to help us get through the hard stuff, to help us see our thoughts for what they are and not what OCD says they are, and to remind us we don’t have to do this alone. Return to top of page
Obsessive compulsive disorder (OCD) involves the triggering of unwanted thoughts, images, or impulses (i.e., obsessions) that provoke feelings of distress in the form of anxiety, disgust, or other negative emotions. In response, people then engage in compulsions in an attempt to reduce or eliminate the distress. This cycle of trigger-obsession-distress-compulsion is reinforced by the temporary relief the person achieves by doing the compulsion. Once the obsession is triggered again, the cycle is even more likely to be repeated. OCD is the fourth most common mental health disorder. Despite how common OCD is, most people still have difficulty getting proper treatment. Many therapists are not trained in Exposure and Response Prevention (ERP) yet still claim to treat OCD. To complicate things further, OCD is not always easy to identify. Most people can recognize excessive hand washing or checking locks as OCD, but there are so many other ways OCD can present that are harder to identify. Harm obsessions Harm obsessions can take the form of harming loved ones or anyone perceived as vulnerable, so people often have fears of harming partners, parents, siblings, children, and pets. It is also common to have fears of harming oneself (e.g., thoughts of driving off the road or jumping from a high balcony). Often, these thoughts are accompanied by a fear of losing control. For example, “what if I lose control and stab my partner while preparing dinner?” These thoughts differ from genuine suicidal or homicidal thoughts in that they are unwanted thoughts and the person has no real desire to act on these thoughts. A very common time for these thoughts to manifest is during pregnancy or after childbirth. Many parents develop obsessions around harming their child during this time. People may also fear causing inadvertent harm to others if they were to cause a fire (by failing to check the stove), burglary (by failing to check the door locks), or car accident (by failing to pay proper attention or check their periphery). Instead of obsessing about losing control, the thoughts here may be more focused on making a mistake that leads to catastrophic consequences. Sometimes harm obsessions manifest as a fear of emotionally harming others. For example, someone may obsess over whether they’ve hurt someone’s feelings and experience intense guilt and anxiety. Or perhaps they obsess about losing control and blurting out something offensive. Regardless of the form of harm obsessions, a common thread is a sense of overresponsibility. Individuals with harm obsessions have core fears involving being a “bad” person, going to prison, ruining lives, and ruining relationships. Common compulsions include checking, mentally reviewing situations or trying to “figure it out,” thought suppression or distraction, internet research (e.g., reading about serial killers or psychopaths), seeking reassurance from others, confessing, apologizing, and avoidance of people or objects. Sexual obsessions OCD can present as intrusive sexual thoughts about someone inappropriate – often family members, friends, children (Pedophile OCD or POCD), and even pets. People may experience sexual images or impulses to act on sexual thoughts. These thoughts are experienced as disgusting and repulsive to the person and, therefore, elicit anxiety and shame. Sometimes these thoughts take the form of “Did I just touch that person inappropriately?” Other times the thoughts could be more like “What if I lose control and do something inappropriate?” There may also be some overlap with harm obsessions as well – for example, obsessions about whether they sexually assaulted someone they walked by on the street. It’s also very common for someone with OCD to question whether they are experiencing pleasure by having the thoughts (although on some level they know these thoughts are not pleasurable and they would do anything to get rid of the thoughts) and to even monitor arousal. Typically, the core fears underlying these types of sexual obsessions are fear of being a “bad” person, fear of going to prison, fear of ruining someone else’s or one’s own life, and fear of ruining relationships. Another subset of sexual obsessions involves doubting one’s sexual orientation. This could manifest in a number of ways. Someone who is heterosexual could have doubts that they might be gay. Someone who is gay might have doubts that they are secretly straight. The important thing here is that there is a need to know with absolute certainty what one’s sexual orientation is, whether it be gay, straight, bisexual, asexual, pansexual, etc. This goes far beyond normal questioning of one’s orientation. Core fears around sexual orientation are sometimes based on fear of losing important romantic relationships if one discovers they’re not the sexual orientation they thought they were. Sometimes the main concern is devastating their partner. Sometimes they worry about their entire life having to change. The core fear could also be about not knowing oneself, or simply the fear of never feeling sure about one’s sexual orientation. Common compulsions include checking for sexual arousal (groinal response), mentally reviewing situations or trying to “figure it out,” thought suppression or distraction, internet research, seeking reassurance from others, and avoidance of people. Relationship obsessions Relationship OCD (ROCD) involves extreme doubt about one’s relationship. These doubts can center around how one feels about their partner or the relationship itself – “Am I attracted enough to my partner?” or “Is this the right relationship for me?” Alternatively, one can struggle with doubts and fears about how their partner feels about them. Sometimes relationship OCD leads to obsessing about a partner’s relationship history – for example, obsessing over the number of sexual partners their partner has had, or feeling the need to know details about their partner’s previous relationships. Core fears with ROCD include fear of being hurt or betrayed, fear of missing out on “the one,” and fear of causing irreparable harm to another person. People with ROCD tend to seek reassurance from their partner that everything is okay. They also may seek reassurance from others about what is “normal” in a relationship or engage in comparing their relationship to others’ relationships. They may monitor their sexual arousal to confirm they are still attracted to their partner. They may also check for sexual arousal around other people. Other compulsions may include mentally reviewing situations or trying to “figure it out,” thought suppression or distraction, confessing, and avoiding their partner or other attractive people who are not their partner. Religious obsessions (also known as Scrupulosity) Religious obsessions or Scrupulosity involves the fear of sinning or doing something morally wrong, including blasphemy. Often people fear sinning or offending God, but sometimes the fears are unrelated to religion or faith and focus simply on a need to do the “right” thing. It’s important to understand that being religious, even deeply religious, does not cause OCD. However, because OCD often attacks the things we care about the most, people who are deeply religious or scrupulous and have OCD may develop obsessions of a religious nature or involving morality. Further, scrupulosity can develop within any set of religious beliefs, whether they be Christian, Muslim, Jewish, or any faith. Core fears may involve being punished, going to Hell, and being a “bad” person. Common compulsions include praying for forgiveness, mentally reviewing situations or trying to “figure it out,” thought suppression or distraction, seeking reassurance from religious leaders, confessing, apologizing, and avoidance of people or objects. Many people who struggle with religious scrupulosity find it difficult to attend religious services or practice many aspects of their faith. Contamination obsessions People with contamination obsessions may have fears of dirt, germs, bodily fluids, chemicals, and diseases. Sometimes these things are feared because they are linked with illness, and other times they may trigger a feeling of disgust. Some may also experience a fear of emotional contamination, which is a fear of taking on or spreading someone’s or something’s essence. For example, they may fear taking on characteristics of selfishness simply by being around someone they perceive as selfish, or they may fear going to a particular place where something negative or traumatic happened due to a magical belief that they will cause something bad to happen. Contamination obsessions can focus on oneself, other people, or both, and this would be reflected in the core fears present. Core fears could include a fear of contracting an illness and dying, or possibly suffering. Perhaps they fear being in a vulnerable state and not believing anyone would take care of them. Or perhaps they fear leaving their family behind and not being able to take care of them. Individuals who mostly fear spreading contamination, much like those with inadvertent harm obsessions, feel overly responsible. Often their core fears center on causing significant illness or death to someone they love. Common compulsions would include excessive hand washing, showering, using barriers like gloves or towels, cleaning/decontaminating items, and avoidance of people and places that are considered contaminated. Symmetry/Order obsessions Lastly, obsessions with symmetry, order or exactness are common. People may have concerns about how items on their desk are arranged, or they may feel unsettled if they experience a sensation only on one side of their body (e.g., bumping their left elbow and feeling an urge to even things out by bumping their right elbow). These can be linked to a magical fear that something bad will happen if an item is left out of order, but often they trigger an uncomfortable feeling of things not feeling “just right.” Compulsions could include ordering and arranging items in a particular way, repeating tasks until they feel “just right,” and “evening out” bodily sensations (e.g., needing shoelaces to be even tensions on both feet). Return to top of page
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