William Gordon on Unusual Obsessions
and Complicated Compulsions
By Lynn Mollick
On Sunday July 17, Montclair psychologist and NJ-ACT member Dr. William Gordon presented his approach to treating unusual obsessions and complicated OCD. Bill emphasized that although cognitive interventions may be helpful, exposure and response prevention (ERP) is the most important component of treatment for OCD. “OCD is irrefutable, and logic will not dispel an obsession.”
Bill pointed out that in vivo exposure is not practical for many obsessive fears because they involve hypothetical future states. But imaginal exposure is infinitely adaptable and therefore can “detoxify” or “diminish” any exaggerated or bizarre obsession. The goal of ERP is to render upsetting, intrusive thoughts acceptable and even boring, not to eliminate them.
Doing Imaginal Exposure
Develop the imaginal exposure narrative during a session. Ask the patient to read the narrative aloud to determine whether the patient can tolerate the anxiety. Begin with less anxiety-provoking scenes, make sure the patient can tolerate the anxiety, then increase the level of anxiety.
Imaginal exposure should be multimodal and should elicit strong emotions and sensations, at least a 6 on a 1-10 scale. Use the patient’s language, and include proprioceptive cues, smells, dire consequences, and the reactions of others in imaginal exposure narratives.
Emphasize that initially exposure should be distressing, but eventually “familiarity breeds comfort.” Recording the exposure on a digital recorder enables the patient to listen to the recording and practice exposure between therapy sessions. Exposure must be repeated and it must be prolonged. Between sessions, patients should do exposure exercises as soon as they experience an obsessive thought.
Getting started with exposure homework is often patients’ biggest difficulty. Bill recommended scheduling short, frequent cell phone contacts to coach patients through exposures. Doing exposure in the situation where an obsession occurs promotes generalization, and since obsessions often occur in the patient’s home, cell phone contacts are an ideal intervention.
Techniques for Enhancing Exposure Effectiveness
Listening to recorded narratives is one form of exposure, but dramatic enactments, stories, movies, poems, even clinical inquiry and discussion are other ways to make patients comfortable with forbidden topics. Make sure in vivo exposure is intense. Gently touching a “contaminated” object with a finger tip is not sufficiently intense. Patients should use their entire hand and really get themselves “dirty.”
Bill noted that OCD patients always fear “sneak attacks” -- intrusive thoughts that appear unexpectedly. Include “sneak attacks” in exposure narratives.
Exposure works best with patients who know that their fears don’t make sense. Metaphors help get treatment concepts across. Talk about OCD as an imp or a poet, refer to treatment as engaging in a battle, reaching peaceful coexistence, or sliding out of a riptide.
Self-talk is also important. For example, “The heart of the danger is where I can find safety” or “it’s hard to do exposure, but it’s harder not to do it” or any other self-talk that resonates with the patient.
Differential Diagnosis of OCD
When patients present repetitive sexual thoughts, therapists must determine whether they are symptoms of OCD, PTSD, a paraphilia, a sexual identity issue, or a normal fantasy. Here are some guidelines:
1. Normal fantasy. The repetitive sexual thoughts are pleasant, guilt-free and arousing.
2. PTSD and OCD. The repetitive sexual thoughts are intrusive, shameful, and guilt-inducing.
3. PTSD. The thoughts are based on an actual traumatic experience; in OCD they are hypothetical.
4. Paraphilias. The patient is aroused by the thoughts and would like to act on them. These patients seldom feel guilty. OCD patients always feel guilty about their obsessions and dread acting on their forbidden sexual thoughts.
5. Sexual identity issues. When patients are uncertain about their sexual orientation, do a comprehensive sexual assessment. Find out who their partners have been, what arouses them, what their fantasies are. Sometimes patients who want to get rid of sexual thoughts don’t have OCD. They just don’t accept their sexual orientation.
Unusual Forms of OCD
Bill described several unusual forms OCD and their treatment:
1. “Need to know OCD” -- Patients hoard useless information. Behavioral experiments are helpful. (Treatment: Don’t find out …. How anxious did this make you? How long did the anxiety last?)
2. “Damned if you do/damned if you don’t OCD.” Anything the patient does feels wrong – e.g. reminding a friend about a health warning scares the patient, but not reminding the friend makes the patient worry about the friend getting sick. Becoming used to discomfort is the goal, and exposure helps.
3. “Conversational OCD” occurs in families. Patients can’t end a conversation unless they believe the family member understands their point. This leads to long and exasperating discussions. Treatment involves self-monitoring, increasing motivation with pro’s and con’s, and encouraging the family to stop trying to demonstrate complete understanding.
The Therapeutic Relationship
Treating OCD is difficult, and patients must trust their therapists in order to endure the discomfort of exposure and response prevention. To create that trust, Bill recommended empathy, calm curiosity, acceptance of patients’ obsessions, a serious but somewhat playful attitude, and confident knowledge of OCD and its treatment.
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