Doing OCD Homework and Fear of Failing

Wednesday in therapy, Leonard had me record a description of the moment at which I feel the compulsion to ritualize, followed by my values list. My homework is to listen to it 12 times a day. The idea is that I will start building new connections to my values, so that when my anxiety spikes, my values have more of a chance of coming to the surface. I've had 15 years of a job where if I started to feel anxious, I could distract myself on the computer, and the habit is deeply ingrained. Now I have all this time at home since I lost my job, and the old critical perfectionist voice is getting loud. "You have all this time now. Why are you wasting it being compulsive?" Which then gets the OCD ramped up, because I don't want to have the thought that I am wasting time, or doing things imperfectly, and I get back on the computer to distract myself and waste more time.

Leonard's idea makes sense to me, but it almost seems to make too much sense(if that makes any sense!!) Some convoluted OCD logic, "This could work, but what if you try it and it doesn't work? And this proves you are a worthless failure. You'd better avoid doing it." I see the irony in the fact that there were many times I wanted to quit my job, because the OCD was so tied to walking into my office, feeling immediately incompetent and scared, and seeing the computer, sitting down and then wondering where the day went. Part of me hoped that if I didn't have the job, my OCD would go away. I remember starting on an SSRI, and having a bad dream that I was starting to feel better, but this meant I would have to stay at my job forever.

I suspected that quitting my job wouldn't eradicate my OCD, and that what I really needed was treatment for the OCD, before reevaluating what to do with my life. OCD isn't very sophisticated, and spent its time screaming, "You are wasting your life at this job," which sent me into a frenzy of compulsive distraction, but OCD couldn't give me any other alternative. And of course, it was the OCD that was mostly responsible for whatever wasting of my life I was doing at work. If there had been a video camera in my office, the film would've shown a woman sitting very still, moving the mouse barely perceptibly with her left hand(because she injured her right hand, and in order to keep websearching, had to switch to her left).

Today has been a lurching through various forms of perfectionism, but I listened to my recording 3 times today so far. I will give myself credit for that.

Finding OCD Support Groups

The International OCD Foundation's new list of support groups is now live! I had started a list of OCD support groups for adults in the US and Canada when the IOCDF's page was under construction. I am going to leave it up for now, but I encourage readers to go to the IOCDF's support group page. You can search by location or alphabetically.

If there isn't a group in your area, there is a link to a manual by Dr. Jonathan Grayson on how to start your own GOAL group. The support group I've attended is modeled on the GOAL group structure of having a time of sharing followed by making a concrete goal for an exposure to do before the next group meeting. It was very helpful to have accountability and support from other people who understood what it's like to have OCD.

OCD Toolbox Flipping a Coin

I noticed a gap between my last two posts, ie. how did I get from vetting my food choices endlessly to having a mediocre lunch on Wednesday and going on with my day. As an aside, OCD perfectionism makes it hard to credit myself for any work I've done, as if somehow I was magically transported from point A to point B, in spite of my general wretchedness. But I know that's not what happened.

One of the most helpful strategies, that my ERP Therapist introduced me to, is flipping a coin. This short circuits all the OCD crap about choosing the "just right" item that won't trigger a cascade of obsessing and compulsing. Instead, I make the choice to jump into the fray, and accept whatever randomly comes up, and live with the anxiety it may cause, until it dissipates of its own accord.This is both terrifying and incredibly liberating.

Often, in facing a menu, I'd go back and forth, back and forth between 2 options, so as an exposure I'd say, If it's tails I'm getting the first item, if it's heads I'm getting the second item. I don't usually have a coin on me, so I started using my watch--if the second hand is in the first 30 seconds of the dial it's one, and in the second 30 seconds it's the other. This also works with digital watches--if the last digit is even vs. odd.

This works best with "yes" or "no" questions, or choosing between 2 things, and only if I go into it intentionally as an exposure, fully aware that I might not like what I end up eating, and get a spike of anxiety that I didn't adequately examine my choices.

It helps to remind myself that even with an hour of indecision, and thinking through every possible option, I could still end up with something I don't like, and I've wasted an hour. I have no special fortune telling powers, and no amount of menu perusing is going to guarantee an obsession free meal.

Of course OCD is clever and tries all sorts of ways to insinuate itself--should I use the coin toss? Is this the right time to do the coin toss? I would fight back by flipping a coin to answer that question.

Related Posts:
OCD Toolbox: Listening to Scripts

Inconsolable OCD Melt Downs

I watched episode 4 of VH1's OCD Project. The person I identified most with in this episode was Kristen. I don't have contamination OCD, but I've been in that paralysis of avoiding doing a task because I will do it wrong and ruin everything. For Kristen, putting away her laundry was a monumental battle that doesn't play as dramatically on tv as eating off a toilet. It took a lot of courage on her part to risk contaminating everything she had just washed, and then be deluged with the anxiety of wanting to clean it all over again. I love her brother Theo. He is her link to the former "free spirit" she said she used to be. He knows she's still in there somewhere.

The phone call between an inconsolable Kristen and Theo, as he gently told her he wasn't going to come get her, was very powerful. He reminded her that what she wanted was to get better, which means putting aside the desperate desire to flee the anxiety. My therapist just recently talked about the parallels between the intense anxiety of obsessions, and a child who is inconsolable. The fear is very "young," and comes from a different place than our adult selves. I recognized the intonation in Kristen's voice. I've done this with my therapist, where he has to guide me from point to point when I was frozen in fear.

But I am troubled by the dynamic between David Tolin and Kristen and his tendency to revert to "black and white, all or nothing" thinking when he interacts with her, with a dose of power struggle thrown in--his insistence on a 5 minute shower as an end to itself, his "either fight the OCD or don't," and the snarky comment about Kristen needing to drop the Princess Act. The therapeutic alliance is really important in Exposure Therapy for a lot of people. The first thing Leonard said to me when we met was, "You have to tell me if you don't like me, because rapport is essential."

Does David Tolin really believe that Kristen is just spoiled and stubborn? He said he wouldn't negotiate with her, that she needed to either do the Exposures or not. For some people, this might work as a strategy, but in my opinion it sucks. ERP has a high drop out rate, which is disturbing, because ERP is a treatment that works for OCD. I believe there is a temptation on the part of some therapists to label someone "non-compliant" if they don't do their exposures, instead of figuring out why they aren't willing to do them, and working to give those reasons less credibility. Even 20 years ago, people with OCD were considered hopeless by much of the therapeutic community. I'm sure it is exhausting being an Exposure therapist at times. It's exhausting living with OCD.

OCD will always want to bargain and argue, but people with OCD are more than just the OCD. The healthy part of Kristen signed up for a hellacious show because she wants to get better. That is who Theo addressed when he talked to his sister on the phone, and he acknowledged the fearful part of her with considerable compassion. When we feel OCD anxiety, it is using our one and only nervous system. It feels real. OCD has no respect for me as a person--it is all about reducing anxiety, even at the expense of having a life. It feels death defying to put away clean laundry if you believe it's contaminated. It isn't pretend. Facing that fear by doing Exposures takes courage, and in spite of the perception of Kristen as a Princess, she is showing a lot of courage.

What should I do next OCD Indecision about what to do when

So what now? This question could stop me instantly. As a college student, I dreaded weekends and holidays, when I had more control over what I could do with my time, because of an obsessive fear that I would choose the wrong thing at any given moment, and be haunted by my mistake, and have to live with intolerable anxiety. Then I got a job working alone, a self-directed, independent position, with no coworkers, and my OCD got worse. Now I had to decide what to do each and every moment, and I was petrified that I would choose wrong.

My compulsion was avoidance of making the decision, through web searching, researching, analyzing and waiting until I felt "just right" about taking an action. If there was an urgent deadline, I could meet it, because I could feel the "rightness" of completing that assignment, but inbetween these islands of clarity was a rushing river of confusion and overwhelm.

On my days off I would stay in bed after the alarm with an ominous sense of inadequacy. What would I do with my day? Would I screw it up? How would I know which things to do and when? Once out of bed, I might think of something to do, and then feel a pervasive dread that I might be making a mistake, and I'd put off doing anything(which of course is a decision in itself). I'd get ravenous because I couldn't decide what to eat for lunch. I'd turn on the tv and flip channels for hours as a distraction. The only thing that saved me from web searching was my slow dial-up connection.

When I started ERP Therapy, I started to realize that I wanted to know for certain what my next action should be, but most people without OCD didn't get stuck on this. From my perspective, it seemed that non-OCD people were randomly guessing what to do next, and that scared me. I also realized that in my indecision I wasn't getting anything done, and I was losing whole swaths of my life to the ritual of choosing "perfectly."

One of my first Exposures that occurred to me, was making a schedule for the day, with a 15 minute time limit, and then following my schedule. I did this for several months, and I learned a lot from it. First, some of my choices were better than others, but I got a lot more done by "guessing" what I might need to do, and in what order. Second, the urge to make a "perfect schedule" was very strong, as was the desire to perfectly follow the schedule, and I practiced purposely choosing something that didn't feel "exactly right," or deviating from the schedule. Third, it helped to record a script about what I was losing when I gave into my compulsions, primarily the direction of my own life, and abdication to the OCD. I felt distress giving up my illusion that I really could choose the right things if I just tried hard enough, but also relief.

OCD Workshops for Parents at the Child Mind Institute in New York City

The Child Mind Institute let me know that they are offering a series of workshops for parents of children with OCD, with the last three being in January, February and March, 2012. All of the workshops in the series are free and open to the public. Here's a description of their mission:

Our Obsessive-Compulsive Disorder Parent Support and Information Group workshop series covers a range of issues affecting children with obsessive-compulsive disorder (OCD) and their support networks, from navigating friendships and family gatherings to the ins and outs of treatment and medication. This program is an opportunity to gain invaluable skills and learn how to help your children take control of their condition and thrive. Below you'll find the dates and topics of the 2011-2012 workshops; descriptions to follow.
This series is brought to you by the Child Mind Institute's Intensive Pediatric OCD Program. All workshops are held at the Child Mind Institute headquarters located at 445 Park Avenue (with entrance on 56th Street), New York, NY 10022.
The Nuts and Bolts of Exposure Therapy
Speaker: Jerry Bubrick, PhD, Senior Director, Anxiety & Mood Disorders Center; Director, Intensive Pediatric OCD Program
Date: Tuesday, January 10, 2012
Time: 6:00PM - 7:30PM
Location: Fascitelli Board Room at the Child Mind Institute
At first glance, the treatment for a child with OCD can seem illogical and difficult—why would my child want to do exactly what she fears? In this workshop, Jerry Bubrick, PhD, Senior Director of the Anxiety & Mood Disorders Center and Director of the Child Mind Institute's Intensive Pediatric Obsessive-Compulsive Spectrum Disorders Program explains why exposure therapy is the gold standard in OCD treatment and how it works to alleviate the extreme anxiety a child experiences around his or her symptoms. He explains how to help your child face the "bully in the brain" head-on and regain control over his or her life.
Is Medication Part of the Answer? Medication Approaches to OCD
Speaker: Roy Boorady, MD, Senior Director of the Child Mind Institute's Psychopharmacology Center
Date: Tuesday, February 7, 2012
Time: 6:00PM - 7:30PM
Location: Fascitelli Board Room
When deciding how to best treat a child with OCD, it is important to be aware of all of the options. Treatment for children with OCD will often involve cognitive-behavioral therapy, medication, or a combination of the two. Roy Boorady, MD, Senior Director of the Child Mind Institute's Psychopharmacology Center and one of the nation's foremost experts in the psychopharmacological treatment of children and teens, discusses medication approaches to treating OCD. You'll gain a deeper understanding of when and how medication should be used in the treatment of OCD as well as the benefits and drawbacks of the different classes of medication available.
Real Stories: Parents Speak
Date: Tuesday, March 6, 2012
Time: 6:00 PM - 7:30 PM
Location: Fascitelli Board Room at the Child Mind Institute
Join us for a very special Q&A panel of parents who've successfully led their children through the challenges of OCD. They will share personal stories—their struggles as well as the successes—of raising a child with OCD. You'll have the opportunity to ask questions and gain insight into how you can help your child while maintaining balance in your life.

Field Guide to OCD Feeling on Trial

I feel like I'm on trial by OCD. This is one of the clues to recognizing being in the OCD. The OCD thrusts the burden of proof on me. I must prove all things beyond any reasonable doubt, which of course, OCD doesn't ever recognize. When I started Exposure Therapy, my OCD had a lot of power and credibility.

Right now, I am on the computer, after being on Skype. I called at 8:00 am, the time I used to start work when I was employed, and once I got off the phone, I was back in my old work pattern of compulsion, which was to stay on the computer, in a kind of trance, because anything else I might do could be the "wrong" thing, and I would be in for harsh cross-examination from my OCD thinking. I'm doing my mental rituals of checking of what time it is, how many minutes have passed, diverted into the "why am I doing this? What is wrong with me?" line of questioning, followed by, "you can't undo this. you've ruined your day, you can't salvage it. you suck."

This adversarial mode adds more fuel to the OCD fire. And OCD talks a confident way, a dictatorial, demanding way that is intimidating, and uses a kind of brute force, saying the same thing over and over, louder and louder. What if! What if! What if!

A cross-examination complete with, "Just answer the question. Don't explain. Just answer yes or no. Strike everything else from the record." What if I am fucking up my life? What if I am making a horrible mistake? What if I really am bad? What if I don't really deserve any compassion? What if I am wasting my life and this is unforgiveable? What if I am beyond redemption?

Often my own thinking seems pallid and inconsequential, signifiying nothing, powerless. But it's my own thinking that allowed me to get into treatment, and start doing things with my life, and learn to have compassion for myself. This is the act of faith, to trust the quiet still voice, without knowing for sure if it really is my own thinking--the OCD chips away at that too, demanding I know for certain if I'm thinking for myself or if it's OCD.

This is crazymaking stuff. Depending on the context, the my current line of questioning can completely contradict another line of questioning from just a second before. From "Don't trust your thinking" to "What's wrong with you that you don't trust your own thinking?" to "Ok. But are you sure this is your own thinking and not the OCD?"

What is the fruit of your OCD? What kind of fruit does it bear? Does it bring peace or joy or meaning to your life? If I am brave and take a minute to observe, I can see the destruction it wreaks, the poisonous fruit OCD bears, the mess my life became when I was totally in grips of it. OCD certainly promises peace, and promises if I just stay at the computer and answer all the questions, that I will avoid the turmoil of getting up, and facing my day in a backlash of obsessiveness, but I know from experience, if I stay on the computer a few more hours, until my back hurts, and I've thoroughly exhausted myself and my mood has deteriorated, that any peace I get is an illusion.

Unhelpful Strategies for my OCD Reassurance Seeking

There is an interesting article on reassurance seeking by Jon Hershfield on the blog of the OCD Center of Los Angeles. OCD is about unwanted thoughts and intrusive images, and the desperate desire to make them go away. Reassurance is, as Hershfield argues, like crack cocaine. There's an immediate hit of relief when getting reassurance that the thoughts aren't dangerous, you aren't dangerous, the world is not dangerous, but it is short lived.

The brain goes "Whoah. This must be serious if I need this kind of reassurance. I need more of it. I need it now." And the OCD desire for certainty feeds the craving for reassurance. I used a lot of Self-Reassurance, which also overlaps with my Research Reassurance.

When I have body symptoms, and OCD is active, I will check to see if they have changed, or check both sides to see if they are the same, or poke and prod at something. It's taken an long time for me to realize that the reassurance makes the anxiety worse and puts me on red alert. Ultimately, I am gaining no useful information when I keep monitoring my body. The mole will probably look the same in 2 minutes, and this neither proves nor disproves its actual danger.

I have also conducted what Hershfield refers to as the "Mental Review"--on getting an intrusive thought about saying the wrong thing in conversation, I would go over it, retrace it, try to figure it out.

Finally, Research Reassurance is a bugger. By age 17 I was looking up medical symptoms in the health section of bookstores, and then in the reference section at my college library. This was before the modern internet, and when graphical browsers went mainstream in the mid 90's, my research took on warp speed. Researching provides the promise of finding an answer, but in the process turns up other scary things, and adds even more to obsess about. There is no website labeled "Exposure Woman: This is exactly what the problem is, and here is the solution."

I also researched my own life experience, by re-reading my old journals, diaries and correspondence, whether letters or email. One of my first Exposures in ERP therapy was putting my journals in a box on a high shelf, and learning to cope with the desire to figure out if I've always had OCD, or if I didn't try hard enough to get help, or learning to make decisions without all the "background information" my OCD thinks I need to make a fully informed choice.

Hershfield ends with a sentence that is a true sign of his clear understanding of OCD cravings to have certainty:

Finally, when it comes to resisting the wealth of information (and misinformation) available from the web and other sources, it’s best to turn the computer off altogether when you find yourself just wanting to know something “for sure.” In fact, there’s no time like the present…so let’s see if you can move on from this blog without knowing for sure if you fully understood it.

Summary of Part 1 of The Mindfulness Workbook for OCD by Jon Hershfield and Tom Corboy

New Harbinger Publications offered to send a review copy of The Mindfulness Workbook for OCD by Jon Hershfield and Tom Corboy(2013).  Since I was in the middle of taking a mindfulness class, it was interesting to read this book with specific connections to OCD.

I am familiar with the writing of Jon Hershfield, as he was the moderator of the online support group PureO for many years, and he had a way of describing obsessive thoughts and ways to face them that was very helpful.

Part 1 covers definition of mindfulness and cognitive behavioral therapy(CBT) terms.

The authors define mindfulness as, "the state of acknowledging and accepting whatever is happening in the present moment exactly as it is(p. 8)."  In my experience, when I have an anxious thought or sensation, I race way ahead of the present moment in trying to figure out what it is or what it means.

The authors argue that, "The problem of OCD isn't that you think too much.  It's that you confuse the intensity, volume or visibility of your thoughts with their importance(p. 12)."  Practicing hanging in there with the intensity or stickiness of the thoughts can allow your mindful self to choose what you want to do with your life, rather than listening to the loudest voice.

The book provides a cognitive behavioral therapy background on distortions of thinking that you can identify in your own thoughts, not as a way to "solve" or "figure out" the thoughts, but to practice seeing them as thoughts.  One of the things that really helped me when I was in therapy for OCD was writing down my thoughts as they happened, as if it were a transcript, but then labeling the distortions in the margin, so I got better at identifying what my mind was up to.

One such distortion is Catastrophizing/Predicting/Jumping to Conclusions.  Accepting I can't predict the future is a bedrock of mindfulness.   As scary as the uncertainty can be, the racing ahead brings forth even more fear.

The book does an overview of Exposure and Response Prevention therapy, and the use of Imaginal Exposure Scripts, another component that helped me in therapy.

Part 2 of the book addresses mindfulness and CBT for specific obsessions with a 3 step process.

1. Acceptance of the presence of OCD thoughts and feelings.  You are accepting that the thoughts are there, not any meaning that you attribute to those thoughts.
2. Assessment using CBT to assess the value of the OCD thoughts, as a nonpartial observer, labeling possible distortions, and returning to the present.
3. Action using behavioral skills to expose yourself to OCD thoughts in order to habituate to them and overcome your fears.

I suspect many readers will turn immediately to Part 2 in hopes of clues to particular obsessions, as the authors say, "The reason we separate obsessions into categories is that for every obsessive-compulsive cycle, there's a way to break it.  There's a way in, and knowing the way in is important  When you understand the mechanics of an obsession can identify the compulsions that hold it in place, you can begin the process of letting both of them go(p. 84)."

I will discuss some of these chapters in future posts, as well as some thoughts on the book as a whole.  

Dealing with Health OCD as a Teenager

I received a poem written by a 16 year old girl who suffers from OCD, and she gave me permission to write about it on my blog.  I feel kinship with her, since I was in the midst of health anxiety OCD at her age.  I didn't have the internet to look up symptoms, but I went to bookstores and libraries and read medical reference books.  I am including a few excerpts from Eliza's poem: 

OCD

In a crowd, it seems impossible to feel so alone . . .

I tell my friend I have a sharp headache,

And I wonder if she knows that the second class lets out

I will immediately look up symptoms

And pick the worst disease

And that I will convince myself that I have

A brain tumor

***

It’s this stupid disease,

That makes me obsess over a single worry,

It’s this stupid disease,

That makes me think I have a million others,

It’s this stupid disease,

That makes me hate myself

But I continue, and no matter how hard it can be

I get through it

And because the worry and fear overcomes me,

It just makes it all the more welcoming

When happiness

Knocks the wind out of me

Health Anxiety OCD is indeed the "stupid disease/that makes me think I have a million others."  I hated myself at 16, hated how quickly and intensely I would worry about pains and spots on my skin and symptoms of any kind.  I believed this was a defect in myself, that I couldn't control the worry.  

I had moments "When happiness/knocks the wind out of me" and these gave me a glimpse of hope that I could feel something besides fear.  

I had never heard the phrase "Obsessive Compulsive Disorder" or the acronym "OCD."  I knew I had anxiety, but that was it.  When I was 19 or 20, my mother was taking classes to become a counselor, and I picked up her DSM, a manual of diagnoses for mental illness.  I don't remember seeing "OCD" but "Generalized Anxiety Disorder" jumped out at me for describing much of what I experienced.  It was a relief that someone could describe this fear.  

The missing component was treatment, and it took about 15 more years until I was diagnosed with OCD and found an Exposure and Response Prevention Therapist.  There was a strong part of me that hung on, in spite of the fear, and I honor that part of myself and that of Eliza.  You are stronger than you know.