OCD CENTER OF LOS ANGELES

COUNSELING & PSYCHOTHERAPY

BRINGING CLARITY TO MENTAL RITUALS

Presented by Jon Hershfield, MFT, Tom Corboy, MFT, Stacey Kuhl-Wochner, LCSW, and Laura Yocum, MS International Obsessive Compulsive Disorder Foundation 19th Annual Conference, Chicago July 29, 2012

The basic rules of behavioral therapy teach us that we cannot control our thoughts and feelings, that we CAN control our behavior, and that our thoughts and feelings change when our behavior changes. For physical behavior, such as washing ones hands, it can easily be understood that an ocd sufferer is physically capable of resisting washing. The compulsion to wash comes from a desire to avoid extreme mental and emotional discomfort that the ocd sufferer associates with not washing. However, not all behavior is physical behavior. While we are not capable of controlling what thoughts exist, we ARE influential in determining HOW we choose to respond to those thoughts mentally. These responses, or behaviors, may take several different forms, but in the case of ocd, they are no less compulsive than furiously scrubbing at the sink. Here is a brief glossary mental compulsions (a.k.a. mental rituals) common to Obsessive Compulsive Disorder. Note that each of them apply not only to thoughts, but to feelings, physical sensations, urges, impulses, and any other internal data that one may experience. MENTAL REVIEW (a.k.a. retracing, replaying, rewinding, ruminating) 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. It also comes in the following forms: MENTAL CHECKING One form of mental checking is occurring when the sufferer is digging up a thought for the purpose of engaging in mental review, also known as a ruminating. 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 ones groinal response to a sexual obsession. This includes mentally investigating the potential source of a thought or feeling to determine why it occurred.

The OCD Center of Los Angeles is a private, outpatient clinic specializing in Cognitive-Behavioral Therapy (CBT) for the treatment of Obsessive-Compulsive Disorder (OCD) and related conditions. 11620 Wilshire Blvd. #890 Los Angeles, CA 90025 (310) 824-5200 www.ocdla.com

OCD CENTER OF LOS ANGELES

COUNSELING & PSYCHOTHERAPY

SCENARIO TWISTING (hypothesizing, theorizing) 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 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 twisting, 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. It is 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 pre-empt unwanted consequences. 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. COMPULSIVE FLOODING 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 critical thinking skills and mindfulness can return. Sometimes sufferers who engage in a lot of obsessional thinking will use this technique as a form of testing their reactions to situations and force themselves to flood 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).

The OCD Center of Los Angeles is a private, outpatient clinic specializing in Cognitive-Behavioral Therapy (CBT) for the treatment of Obsessive-Compulsive Disorder (OCD) and related conditions. 11620 Wilshire Blvd. #890 Los Angeles, CA 90025 (310) 824-5200 www.ocdla.com

OCD CENTER OF LOS ANGELES

COUNSELING & PSYCHOTHERAPY

SELF-PUNISHMENT For ocd sufferers who experience a lot of guilt feelings, mental self-abuse and self-punishment is often utilized. This is also very common in depression. 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. While this is obviously uncomfortable, it is nonetheless compulsive because it functions by avoiding the discomfort of feeling like they have escaped justice.

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 ones religious faith. 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 cod 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. It was long believed that people who were not doing noticeable physical compulsions were purely obsessive (sometimes called Pure O) but it is now understood that mental compulsions play a key role in all forms of Obsessive Compulsive Disorder. Treatment for reducing mental compulsions involves the same approach widely understood to be effective for OCD in general, which is cognitive behavioral therapy (CBT). In addition to traditional CBT however, a heavy emphasis on Mindfulness may be a useful tool for combatting mental compulsions.
The OCD Center of Los Angeles is a private, outpatient clinic specializing in Cognitive-Behavioral Therapy (CBT) for the treatment of Obsessive-Compulsive Disorder (OCD) and related conditions. 11620 Wilshire Blvd. #890 Los Angeles, CA 90025 (310) 824-5200 www.ocdla.com

OCD CENTER OF LOS ANGELES

COUNSELING & PSYCHOTHERAPY

Developing Mindfulness skills can aid in the ability to observe urges to do mental rituals before they start, to identify them without judgment when they are happening, and to develop a capacity to process what was going on after they may occur. From this standpoint, a sufferer can work on removing themselves from the compulsion and bringing themselves back to the present to focus on accepting and tolerating the ocdfueled discomfort. The list above is by no means an exhaustive one and our understanding of mental rituals continues to evolve. But with the help of an ocd specialist trained in mindfulness-based cognitive behavioral therapy, no ocd sufferer should have to consider themselves untreatable or alone for doing compulsions inside instead of out.

The OCD Center of Los Angeles is a private, outpatient clinic specializing in Cognitive-Behavioral Therapy (CBT) for the treatment of Obsessive-Compulsive Disorder (OCD) and related conditions. 11620 Wilshire Blvd. #890 Los Angeles, CA 90025 (310) 824-5200 www.ocdla.com