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Jon Hershfield - Mind Washing: Mastering The Unique Challenges of Metal Rituals


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For the 2016 Annual OCD Conference

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Jon Hershfield - Mind Washing: Mastering The Unique Challenges of Metal Rituals

  1. 1. MINDWASHING: MASTERINGTHE UNIQUE CHALLENGES OF MENTAL RITUALS Jon Hershfield, MFT MonnicaWilliams, Ph.D. Elspeth Bell, Ph.D. Jeff Bell The 23nd Annual IOCDF Conference Chicago, IL July 29th 2016
  2. 2. Why this talk? • OCD sufferers often unaware of role of mental rituals or unable to articulate experience of them • Clinicians often misdiagnose OCD as GAD or other disorders • Both need a language for assessing and treating OCD in the absence of overt observable rituals
  3. 3. OCD BASICS • Obsessions – unwanted intrusive thoughts that are associated with discomfort, often repetitive, typically ego dystonic • Compulsions – physical OR mental behaviors engaged in for the purpose of seeking certainty and relieving discomfort associated with obsessions
  4. 4. But the DSM says… • Presence of obsessions OR compulsions. • But really people with OCD have obsessions AND compulsions (Williams et al., 2011; Leonard & Riemann, 2012). • You just have to be able to identify the compulsions!
  5. 5. “PURE O” OCD • Misnomer used to identify sufferers whose compulsions are primarily mental or covert • Term “pure obsessional” showed up in early 90’s, then replaced with “primarily obsessional” • Is not a clinical reality or separate diagnosis from OCD • Label used by sufferers for fostering sense of community
  6. 6. Rates of Covert Compulsions by Primary ObsessionType
  7. 7. OBSESSIONS • All obsessions involve mental rituals, though some are more commonly associated with “pure o” or invisible compulsions
  8. 8. OBSESSIONS • Contamination obsessions may involve physically washing, cleaning, and avoiding, but also involve significant mental rituals • Responsibility obsessions may involve repeating and checking, but also involve significant mental rituals
  9. 9. COMMONLY ASSOCIATEDWITH SIGNIFICANT MENTAL RITUALS • Harm OCD – obsessive thoughts of aggression, fear of acting out violence impulsively or self-inflicting harm
  10. 10. COMMONLY ASSOCIATEDWITH SIGNIFICANT MENTAL RITUALS • Sexual Orientation OCD (a.k.a. HOCD) – fear of “turning into” or being in denial of other- orientation identity
  11. 11. COMMONLY ASSOCIATEDWITH SIGNIFICANT MENTAL RITUALS • Pedophile OCD (a.k.a. POCD) – fear of being sexually attracted to children or impulsively acting out sexually with children
  12. 12. COMMONLY ASSOCIATEDWITH SIGNIFICANT MENTAL RITUALS • RelationshipOCD (a.k.a. ROCD) – fear of inadequacy or dysfunction in romantic relationship
  13. 13. COMMONLY ASSOCIATEDWITH SIGNIFICANT MENTAL RITUALS • Scrupulosity – religious or moral rigidity, fear of being disconnected from faith, blaspheming, or being morally inadequate
  14. 14. COMMONLY ASSOCIATEDWITH SIGNIFICANT MENTAL RITUALS • Hyper-awareness obsessions – discomfort associated with awareness of involuntary processes (i.e. blinking, breathing, swallowing, or thought process)
  15. 15. MENTAL RITUALS • Thoughts as contaminants of the mind • Some people wash their hands, some people wash their minds
  16. 16. MENTAL RITUALS • Covert compulsions • Often un-noticed by others • Often overlooked by treatment providers • Sufferer may be unaware or believe mental behavior to be non-compulsive
  17. 17. MENTAL REVIEW • 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.
  18. 18. MENTAL REVIEW • Often confused with “just working it out” or honest attempt to gain insight into or understand meaning of obsession • Interchangeable terms - retracing, replaying, rewinding, ruminating
  19. 19. MENTAL CHECKING • “Digging up” a thought for the purpose of engaging in mental review. 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.
  20. 20. MENTAL CHECKING • Can also be applied to feelings and bodily sensations, such as in checking one’s groinal response to a sexual obsession. This includes mentally investigating the potential source of a thought or feeling to determine why it occurred.
  21. 21. SCENARIO BENDING • Hypothesizing, theorizing, exploration of whatWOULD happen • 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.
  22. 22. REVERSE RUMINATING • Mental rehearsal • 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 bending, 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. • 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.
  23. 23. 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 preempt unwanted consequences. • Can include intentional focus on opposite feelings to neutralize intruding ones.
  24. 24. 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. • May involve mental review of previously acquired reassurance.
  25. 25. SELF-REASSURANCE • Contingency planning – reviewing fantasy scenarios in which the feared consequences are coped with or neutralized (e.g. repeatedly telling yourself you’ll escape to Argentina to avoid prosecution for a feared crime) • Suicide fantasies – function as a wishing ritual, imagining a space in which the thought ceases to be present or as a contingency plan (see above). Must be distinguished from actual ideation or intent. • Celebrating – Excessively focusing on moments wherein the unwanted thoughts are absent, self-reassuring that they are really gone and not coming back.
  26. 26. COMPULSIVE FLOODING/TESTING • 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 habituated. • May be distorted into a form of testing reactions to situations by forcing 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).
  27. 27. COMPULSIVE FLOODING/TESTING • Can be associated with “backdoor spikes” in which sufferer is concerned that they are not as anxious about a thought as the “should” be. • Often goes un-noticed by treatment providers but causes unnecessary suffering with no habituating payoff • Sufferer unlikely to even mention it as a compulsion because it is painful, overlooking that it is still a form of checking and avoiding discomfort with uncertainty
  28. 28. SELF-PUNISHMENT • 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.
  29. 29. SELF-PUNISHMENT • While this is obviously unpleasant, it is nonetheless compulsive because it serves to avoid the discomfort of feeling like they have escaped justice. • Often overlooked as simply a product of perfectionism and low self-esteem. • Important to address as a voluntary behavior, separate from the intrusive negative self-thoughts or cognitive distortions.
  30. 30. MEMORY HOARDING • As in physical hoarding, theOCD 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.
  31. 31. 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 one’s religious faith. • May also be engaged in as a form of thought neutralization even when obsession is non-religious in content.
  32. 32. 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 OCD 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.
  33. 33. MATHEMATICS • Mentally reviewing the number of times an event occurred and/or the dates of events in an attempt to determine the severity of an event and self-reassure. • For example, someone obsessing about their sexual past may attempt to form in their mind a statistical average of sexual partners over time in an attempt to feel certain that they have not been promiscuous.
  34. 34. MENTAL CHANTING • Mentally repeating words or phrases, whether positive, neutral, or upsetting, by rote. • May be done a certain number of times or until a desired feeling or mood is established. • Must be intentional and distinguished from intrusive uncontrolled repetition of thoughts.
  36. 36. MINDFULNESS • Acceptance of presence of thoughts, feelings, and physical sensations without judgment • Developing skill of acknowledging and walking away from mental rituals and toward the present • Noticing urge to ritualize and accepting as part of present state without responding • Using meditation and “mindfulness in the moment” as practice • “Noting” as a strategy for reducing mental ritual • Purpose: increase awareness of when distracted and return to present moment without further analysis
  37. 37. Cognitive Restructuring • Identifying and challenging cognitive distortions – patterns of thinking that promote ritualizing (i.e. all-or-nothing, catastrophizing, emotional/magical reasoning) • Not about disproving fears, but about disengaging from “need” to ritualize by acknowledging uncertainty • Important to keep brief and secondary in order to avoid becoming a self-reassurance ritual • Watch for “rationalizing” • Positioning self as observer of thought process
  38. 38. EXPOSUREWITH RESPONSE PREVENTION (ERP) • Essential for all forms of OCD • Include imaginal exposures (a.k.a. scripting) when in vivo unrealistic (may be more effective to use fresh- written scripts to avoid mental rituals instead of loop tapes or repetitive reading scripts) • Goal of triggering urge to ritualize for the purpose of habituation and development of resistance skills
  39. 39. HAVINGTHOUGHTSVS THINKING • Having thoughts – the uncontrollable appearance of an idea (thought, feeling, sensation) • Thinking – the voluntary behavior of analyzing an idea (thought, feeling, sensation)
  40. 40. BACKGROUND NOISE • Some mental rituals may become an automatic thought process that continues despite treatment • Focus on controlling the controllable and accepting the uncontrollable
  41. 41. LABEL AND ABANDON • Core concept of addressing mental rituals is to educate sufferer to identify and label mental ritual as a behavior, then abandon before completion (“OK, I’m reviewing, don’t need to do this right now, walking away”) • Expected consequence is feeling of incompleteness and irresponsibility • Goal is to catch and release sooner and with less effort • NOT thought-stopping… ritual stopping!
  42. 42. Distraction • Can be used compulsively or as a tool for interfering in mental rituals • Purposely interfering in ability to think by confusing self during mental ritual with competition – e.g. remembering lyrics to a song or the sound of a 56k modem
  43. 43. Novel ERP Games • GrandTheft Auto at the Mall ERP (purposely opening up to all obsessive thoughts in a public space without engaging in mental rituals) • Exercise,The Exercise (purposely exposing to obsessive thoughts during first half of an activity, then employing distraction in second half)
  44. 44. FINALTHOUGHTS • Therapists treating OCD must consider all rituals, not just physical ones. Even when physical rituals are properly addressed, sufferer may sublimate them with mental ones and remain similarly impaired. • Sometimes helpful to frame course of CBT as getting the physical compulsions ceased and out of the way for the purpose of addressing the mental ones that bolster the obsession.
  45. 45. FINALTHOUGHTS • Sufferers benefit from understanding mental rituals as compulsions, a behavioral aspect of obsessive compulsive disorder and not a separate issue or diagnosis • There is no “PURE O” beyond the name and obsessions with primarily mental rituals are equally treatable with CBT
  46. 46. references • Williams, M.T., Farris, S. G.,Turkheimer, E., Pinto, A., Ozanick, K., Franklin, M. E., Simpson, H. B., Liebowitz, M., & Foa, E. B. (2011). The Myth of the Pure ObsessionalType in Obsessive-Compulsive Disorder. Depression & Anxiety, 28, 6, 495-500. • Leonard, R.C. & Riemann, B.C.The co-occurrence of obsessions and compulsions in OCD. Journal of Obsessive-Compulsive and Related Disorders 2012;1:211-5.
  47. 47. contacts • Jon Hershfield, MFT –, • MonnicaWilliams, Ph.D. –, • Elspeth Bell, Ph.D. –, • Jeff Bell –,