Jonathan Grayson Addresses NJ-ACT on Intolerance of Uncertainty in OCD
Part 2 – Treating Various Types of OCD
By Lynn Mollick
Los Angeles psychologist Dr. Jonathan Grayson presented NJ-ACT’s 23rd annual
Master Lecture on March 18, 2018. This article is the 2nd part of our summary of his
presentation.
Scrupulosity OCD is a form of OCD which includes being uncertain of your belief in God, wondering whether you are evil, doubting whether you performed religious rituals properly, and fearing you will be condemned to hell.
Since no one can be certain that God exists or know precisely God’s demands, define believing in God as a decision. Tell patients to reject the “OCDemon” and decide to live believing in God and fulfilling God’s requirements as best you can. At the same time, accept that it is never possible to be certain that your faith is pure and your religious practices are correct. You cannot even be sure that you will not go to hell. Scrupulosity scripts should describe the experience of eternal damnation.
Pedophile OCD is the obsession “what if I’m a pedophile?” and trying to convince yourself you are not. Since these patients never have plans to sexually abuse, you can safely tell them you will treat their fears as OCD and help them live with their doubts. But if it turns out that they are truly pedophiles, you will help them accept their shame and be happy pedophiles.
The script for pedophile OCD should be details of whatever they fear most – shame, going to jail, being shunned by their families and society. How would the patient cope?
There are many possibilities for exposure: watching TLC’s “Toddlers in Tiaras,” looking at pictures of JonBenet Ramsey, changing a baby’s diapers, fondling a child’s underwear or clothes.
Violent Obsessions. These OCD patients wonder if they will go crazy, lose control, and perform some violent act. These patients then obsess about what the thoughts mean about them as a person. Successful treatment means accepting the possibility of being violent, whatever that means about them as people.
Scripts for violent obsessions should describe what the patient will do when they go crazy and/or lose control, as well as what will ultimately happen to them and what their violence means. If the worst happens, would they always feel so badly about themselves? What would life be like post-violence? How would they forgive themselves?
There are many possible exposures for violent obsessions. Some examples include: touching knives, holding knives over the wrist or on the neck, watching violent movies, carrying a pocket knife wherever you go, and red dot reminders to consider feared outcomes throughout the day.
Health Anxiety (hypochondriasis) patients have obsessive thoughts such as “what if I have cancer or HIV?” The treatment goal is to help these patients accept that they might have the disease even though symptoms have not appeared. Help these patients stop their futile checking and reassurance seeking so they can live their lives as happily as they can until they become ill. If the disease is asymptomatic, patients can never be certain whether they have the disease. Exposure for health anxiety involves imaginally experiencing the consequences of having the feared illness.
Obsessing about the unavoidable includes problems that are always present like tinnitus, a song stuck in your head, or hyperawareness of sensations such as breathing, misophonia, swallowing, or one’s heartbeat. These patients are uncertain about whether the symptom will ever go away or if they will ever have a satisfying life. The goal of treatment is acceptance, learning to live with the problem. Possible interventions include:
1. Attention re-focusing, i.e. learning to shift focus from the disturbing sensation to the rest of the environment. Tell the patient: “You can’t get rid of the sound/thought/sensation, but you can make a decision about what you attend to.” To demonstrate what he meant, Dr. Grayson played loud music while he spoke to the audience.
2. Focus on values and living life in spite of the problem. Help patients think about what’s good in their lives instead of what’s bad. Perhaps having the problem is not be ideal, but is everything ruined now and forever?
3. Accept good enough. Patients often fantasize that life before they
experienced their problem was idyllic. They also imagine that without the problem, the future will be perfect. But life always has difficulties. Question patients about what really lies ahead.
4. Exposure cues. Use scripts and red dots to cue the obsession and make the obsession impossible to avoid.
Mental Compulsions
Thoughts become mental compulsions when
1. Patients want to know what the thought means, or
2. Patients want to get rid of problem thoughts. Reasoning and analyzing is a mental compulsion that some OCD patients use to diminish distress. Since they can never be certain what a thought means, and the thought keeps intruding, the mental compulsion of reasoning and analyzing continues during much of their day.
Dr. Grayson recommended “scripts” to interfere with reasoning and analyzing. Scripts are imaginal exposures, detailed descriptions of the feared consequences that the patient has recorded. Patients should wear headphones and listen to the script as much as reasonably possible.
Another strategy for learning to live with uncertainty is to post red adhesive dots around patients’ environment to cue them to think about feared outcomes.