Jon Hershfield's Blog, page 2
February 24, 2019
Moral Scrupulosity OCD: Part Three
Moral scrupulosity OCD, or the relentless pursuit of certainty about one’s morality, can feel like a truly impossible situation. You have a thought about something you did or thought about doing, or felt an urge to do, and so forth, and because this experience doesn’t line up with your presumed identity as a moral person, you feel bad. Because you feel bad, you try to get the feeling to stop. You may seek reassurance, try to make sure you’re not doing bad things, check to see if you have, and engage in other compulsions. You set up a rigid rules that apply only to guarantee you’ll never do a bad thing, but since these rules are impossible to follow perfectly, they also make you feel bad.
What’s worse, ceasing to feel bad makes you feel like you’re getting away with something, like you stopped caring about your moral compass. Bad feelings at least reminded you that you care and reassure you that you would never intentionally be immoral. So you find yourself trying to get away from the pain of bad feelings while at the same time clinging to those bad feelings for proof of inherent goodness. Ultimately, this compulsive relationship to moral doubt sends the message to your brain that thoughts about morality are codes to be cracked, problems to be solved. So, the brain faithfully performs its duty to help you by sending more intrusive thoughts and feelings your way.
Getting Your Moral Hands Dirty
Exposure and response prevention (ERP) therapy for moral obsessions can easily miss the mark if no attention is paid to compulsive guilt. It may appear as if ERP for moral scrupulosity is just about bumming yourself out all the time. But for ERP to be at its most effective, you have to expose both to the fear that you may be morally imperfect and also to the fear that you have inadequately addressed it. It’s this second part that people sometimes forget to engage in treatment. In other words, telling yourself that you may have done something immoral can bring up painful feelings, but what you do next is what teaches the brain to change its perspective on how to handle that idea. If you take that pain and beat yourself over the head with it, you’re doing the E of exposure by telling yourself you may have done a bad thing, but not the RP, the response prevention, of behaving like a person whose morality is not in question.
Sometimes this concept is easier to understand by switching it out with another common obsession, like contamination. ERP for contamination fears involves exposing to triggering experiences (E) to generate the feeling of being dirty, but then intentionally behaving like someone who is clean (not washing hands and also cross-contaminating to other objects and environments). So you get the dirty feeling, but you pair it with the behavior of a person who feels clean. In terms of moral scrupulosity, you want to generate in your exposures the difficult feelings you connect to morality, that sense of moral contamination, and pair it with the behavior of a person who is confident in their moral cleanliness.
So what does this really look like? Here are some mock examples (not mocking
examples, which would be wrong):
The “I Shouldn’t Think That” Thinker
You get intrusive thoughts about people that you believe are
immoral to think or would be immoral to say (e.g. racist or misogynist thoughts). It makes you feel guilty around triggering
people and leads to a back and forth in your head of self-reassuring that you
would never mean those things and self-punishing for having thought them in
case you meant them for a second.
Exposure:
Intentionally think the thoughts around
triggering peopleRead about people who like these thoughts and
tell yourself you could be like themWrite scripts describing yourself believing the
thoughts and the implications about you that come with this
Response prevention:
Don’t avoid triggering people, continue to
interact and be friendlyNo reassurance-seeking regarding your beliefs
about the thoughtsLabel self-criticism for having the thoughts as
compulsive and congratulate yourself for coming up with such a creative
obscenity. Actively try to enjoy them if
any part of you thinks they’re funny, even if it would horrify your
sensibilities to say them.
The “I Did a Bad Thing” Thinker
You made a poor choice at some point and now your OCD says you have to be certain that you learned from it and that it will never happen again. Sometimes you want to be certain you’ll get over it, but sometimes you’re afraid to get over it because being obsessed with it feels like it may protect you from doing it again or at least give you certainty that you’re not the kind of person who would if given the chance. You may want to forgive yourself, but rationalizing what you remember about your experience just makes the OCD worse. Or you may refuse to forgive yourself because compulsively clinging to guilt means you haven’t forgotten what you’ve done.
Exposure:
Intentionally be around people or places that are associated with the memoryWrite scripts describing the event in a facts-only way (no analysis of the meaning or context of the event) and describe how awareness of the event may be a permanent fixture in your life or how getting over the event may lead to negative outcomes
Response prevention:
Catch and abandon any mental review of the
event, especially any rationalizing over why the event occurred or why it won’t
be repeatedSeek no reassurance about the meaning of the
event or your characterFully engage in the present by actually allowing
yourself to enjoy something (mindfulness is a major asset here). Remember, OCD wants you clinging to guilt, so
embracing a joyful moment is an act of rebellion.Find activities to do that you imagine people do
when they believe themselves to be good, innocent, or having served their time.
The “Doing No Harm” Thinker
You may avoid doing things where there is a slight chance of inadvertently harming others in the process (e.g. any task involving chemicals that could go astray). When you try to engage in these tasks, something always comes up where your mind can make an argument that the potential of a problem means you need to be excessively responsible (e.g. thinking that if you don’t remove the shiny object from the street, an accident caused by a driver being distracted by it would be your fault). See the previous installment in this blog series for a list of cognitive distortions that make this way of thinking possible.
Exposure:
Do things you genuinely want to do even if it
means interacting with calculated risk (e.g. the safest driver still takes on
risk)Write scripts about having possibly missed a
detail or failed to engage a safety measure and the unwanted consequences
thereofInteract with objects and environments where it
is not totally clear how to do it “right” or where you are less certain you’ve
followed each step correctly (e.g. move quicker through an activity, allow
yourself to be slightly distracted by music or conversation)
Response prevention:
No rationalizing why it was ok to do the
exposureNo reassurance seeking about the likelihood of
negative consequences having occurred or potentially occurringNo checking to make sure unwanted events haven’t
occurred or that all safety measures have been doneActively celebrate the completed task even while
having thoughts about having done it irresponsibly (e.g. brag about your
bratwurst while knowing you may have spilled a little lighter fluid on the
ground by the barbecue)
For Goodness Sake
Part One of this series includes a decent sized list of moral obsessions that people struggle with. Obviously, that doesn’t get at every one. For one thing, our morals evolve over time, so we keep finding new ways to obsess about them. In the end, the most important thing to understand about moral scrupulosity is that we’re all in the same boat. We’re all grappling with moral uncertainty and striving to be more confident in our “goodness” in society. We can argue over whether or not your morals and mine are both right even when they may be different, but we have to admit in the end, we are both guessing.
OCD tries to make it seem like it’s not ok to guess, like there’s some way you can be certain you’re always doing the right thing, and that if you haven’t identified what that way is, then you’re already a moral failure. Like the metaphor of putting your oxygen mask on before your child’s during a plane emergency, you can make the choice to put first your enjoyment of life, engagement with family, presence of attention to the big-ticket items in your story that you really care about. Maybe that’s all ERP is really about, taking the risk of putting yourself first. This is what leads you toward being the most positive contributor to the world around you, presence and connection.
OCD claims that you must first be certain of your morality and you must hold on to guilt for any misdeeds, real or imagined, as proof of purchase in this agreement. It wouldn’t be the first thing OCD is wrong about.
Click HERE to read Moral Scrupulosity: Part Two
Click HERE to read Moral Scrupulosity: Part One
Jon Hershfield, MFT is a psychotherapist in director of The OCD and Anxiety Center of Greater Baltimore. Follow him on Twitter and Facebook.
The post Moral Scrupulosity OCD: Part Three appeared first on OCD & Anxiety Center of Baltimore | Jon Hershfield, MFT.
December 1, 2018
When OCD Comes Home for the Holidays
It’s that time of year again! If you live anywhere near me, the days are shorter, the, weather is colder, and the OCD is counting the ways it can get to you. It’s the most… (jingle jingle) obsessive tiiiime… (jingle jingle) of the yeeearrrrr…
The several weeks of time between Thanksgiving and New Years, or what some people call “Christmas,” can be especially challenging when you have OCD. Triggers you might normally avoid become inevitable, pressures to behave a certain way, to be joyful even, become intensified this time of year and can be overwhelming. Staying on top of your OCD-fighting skills and maximizing your ERP efforts can function as a preemptive strike that helps prevent relapse and backsliding as the year comes to a close. But it isn’t always so easy when the season ramps obsessions and anxiety up.
Any type of OCD can be exacerbated by the holiday season. Here are a few examples I’ve heard in clinical practice.
Contamination obsessions:
The holidays often involve cooking, spending long hours in closed quarters with raw meat, grease, and other things OCD likes to make an issue of.
Buying and wrapping presents, not knowing who touched them before you and exactly who will touch them after you and when – this can be low hanging fruitcake for OCD.
Being around family members and friends in your home or in theirs means not everyone knows where to put their jacket, where to sit, or whether to take off their shoes. The holidays can mean letting go of a lot of control.
Harm obsessions:
Being around knives and cookie cutters when you deal with intrusive violent thoughts can be extra challenging this time of year, especially when children and grandparents are around.
Being around lit candles, electric lights on trees, using ovens, overnight slow cookers, and other things that could have killed Jack Pearson on This Is Us means sitting with a variety of catastrophic hyper-responsibility thoughts and greater urges to check.
If you drink alcohol, you may be drinking more than usual, which comes with the OCD hangover and intrusive thoughts of what you “might have done” when you weren’t yourself.
Sexual obsessions:
If you struggle with intrusive sexual thoughts, exposure to nieces, nephews, and other children you might not usually be around can be extra triggering
Memorable calendar events can come with additional pressure to focus on your sexual or gender identity and seek certainty about who your OCD says you are
Religious obsessions:
If you’re not Christian, living in a predominantly Christian society this time of year means being constantly reminded of another religion. The lights sure are pretty, but OCD may make you wonder, does your religion allow you to recognize this fact or is that blasphemous?
If you don’t subscribe to a religion, the holidays can still stir up existential quandaries that suddenly seem important to solve.
If you are Christian, worshipping the almighty sale at Target can be a lot of fun, but your OCD may tell you that you’re sinfully disregarding the religious aspect of the holiday.
Moral and emotional obsessions:
Gift-giving and receiving can be hard for those with moral scrupulosity who may get stuck on whether the quality or sentiment of each gift they give correlates perfectly to what they receive.
Holiday OCD can sometimes generate excessive concern about not having the right emotions or memories, as if your mind’s job is to create the perfect holiday postcard each year in thought, feelings, and sensations.
This is by no means an exhaustive list, and part of getting mastery over OCD is learning to marvel at its creativity with each new trigger. Here are a few tips on making the most of the weeks ahead:
Don’t let “Obsessive Christmas Disorder” get under your skin
Something about the holidays brings out the best and worst in people, and the worst in people can manifest as a store selling a sweater that says Obsessive Christmas Disorder or as jokes about being “sooo OCD” about holiday decorations. But if you actually have OCD, your cute little Christmas disorder probably looks more like you holding back tears at dinner because you think you did something sexually inappropriate by allowing yourself to finish wrapping your nephew’s present even though you had an intrusive thought half way into it. You absolutely can speak up and let the purveyors of this nonsense know how insulting they are being, but only do so if this empowers you and feels like a skillful use of your attention. You are no less cool if you just shrug it off and tend to other things you value.
Don’t get better for the calendar’s sake
The holidays also come with a lot of internal pressure to “get better” before the year ends so you’re not starting another year with your unwanted thoughts and rituals. This pressure only exacerbates your symptoms and makes you feel more like a failure. Nothing actually happens between December 31st and January 1st. The Earth just completes another revolution around the sun. But it sure feels like an opportunity you’re destined to miss somehow. Stay the course with your ERP and treatment in general. Fight as hard as you always do against the disorder, but don’t go on some sort of OCD diet you’ll end up rebounding from. The calendar doesn’t care about your story.
Give yourself the gift of support
If you have friends or family who know about your OCD, this would be a good time to let them know December may be especially challenging for you. Knowing that there is a safe, non-judgmental person to confide in can make a huge difference. Therapists are good for this too, I am told. Now is not the time to take a break from therapy if you don’t have to. If you can, keep your distance from that family member or friend who puts you down or uses your OCD to shame you, and lean harder on the people who get it and can help you navigate the challenges that come up. To be clear, this doesn’t mean asking for more reassurance. Quite the opposite, it looks more like letting those you normally seek reassurance from to remind you of your treatment goals and empower you to stick to them.
Don’t overprotect memories
The most common pitfall I see in clients with OCD around the holidays is trying too hard to make sure the memory of the event is pure and clean. Maybe your OCD is the most memorable part of some holiday years ago and you desperately don’t want to relive that again. Or maybe your mind is telling you that you have to hoard each memory of the holiday because you’ll want to look back on it like a mental scrapbook and know it was a great season. Like any form of OCD, trying to control the thoughts we have simply opens the gates to the thoughts we don’t want to have. So if this Hanukkah is the one where you thought about burning the house down with the menorah or this Christmas you thought about feeding contaminated cookies to your children, know that these thoughts only have as much power as you give them. If you want good memories of the holidays, create good strategies for responding to OCD.
Stay on top of your meditation game
It all goes by so fast. 2018 is almost over and one day someone will read this blog and say, “2018? I remember back then. We still had wires to plug things in back then. What a joke! Alexa, make me a sandwich!” It all goes by so fast, in part, because we are distracted. We simply aren’t there for some significant part of the adventure because we’re lost in thought, lost in stories, lost in ritualistic strategies to get rid of anxiety and uncertainty. Being mindful means being present for the whole show, acknowledging your five senses and your stories as objects of attention in the present. The best way to strengthen your ability to recognize when you’re lost in distraction is to meditate. Don’t let all the shopping, cooking, and visiting relatives keep you from practicing this skill. Take your time to step out and at least get a quick session in every day. When you come back, you’ll get more out of your experience.
Let self-compassion be your ugly sweater
When stress goes up, OCD goes up, and if the holidays and your OCD leave you out in the cold, wrap yourself in self-compassion. Corny, I know, but tis the season. All of this pressure to be joyous and grateful and jolly can make you feel like a real piece of garbage sometimes. But if you remember that it’s actually ok to treat yourself like you might treat your best friend, you’ll fare a lot better. What about all the compulsions you’re not giving into right now? Who’s going to give you credit for that if not you? Instead of beating yourself up, you can take a beat to acknowledge that sometimes it really is just this hard to battle OCD. The reason isn’t because you’re a failure. It’s this hard because you’re actually trying to break free of OCD’s “danger programming” and trying to show up for the occasion when the disorder wants you all to itself. Invite yourself to do something helpful when you’re feeling stuck, whatever that means to you. Whether it’s reaching out for additional support, letting up on self-criticism when you’re feeling triggered, or taking the opportunity to dive into exposures to your fears, self-compassion offers more than simply “getting through” the holidays.
So may the days between now and a month from now be characterized by empowerment, self-kindness, and good fortune on the journey to overcome OCD! Also, stay out of chimneys. That looks dangerous.
Jon Hershfield, MFT is a psychotherapist in private practice and director of The OCD and Anxiety Center of Greater Baltimore. Follow him on Twitter and Facebook.
The post When OCD Comes Home for the Holidays appeared first on OCD & Anxiety Center of Baltimore | Jon Hershfield, MFT.
October 31, 2018
Moral Scrupulosity OCD: Part Two
When I was a kid, my parents had their driveway repaved and this left a glorious mound of dirt at the top of it for a few days. It was probably ten feet tall and I was clearly told not to play on it, but the moment my mom and dad were off running an errand, I was all over that thing. It was a lot of fun for my toy soldiers and trucks, not to mention the full-body dirt-sledding. The second my mom came home, I felt something in my chest and my throat that I knew immediately I could not tolerate feeling for very long. I could not wait to tell her what I had done. Oh the sweet relief of confession! She was upset with me, but what I remember most was that she was put off by the confession itself as much as by the misdeed. It was bad that I broke a rule, but she didn’t get why I would go out of my way to tell her. Maybe she thought I was gloating, but I remember thinking it could not have possibly gone down any other way. I was not going to feel like a bad kid for a second longer, even if it made me look like a jerk.
Moral scrupulosity OCD often cuts much deeper than this.
A child may keep repeating the details of an event at school for fear that she left something out that would render the story less than perfectly honest.
A woman may feel completely frozen in guilt for days for allowing herself to laugh at a funny movie, forgetting for a moment that she was grieving the loss of a loved one.
A man may desperately avoid being in the same supermarket aisle as an attractive woman and then repeatedly confess to his wife that he found someone attractive – all so he can feel moral about his wife having full disclosure as to who she really married.
A woman may donate large sums of money to any organization that solicits it or she may force herself to do favors for anyone who asks even when she doesn’t have the time – all out of fear of being or appearing selfish.
A man may think an actress in a pornographic video looks disturbingly young and devote endless energy to trying to find out if he’s committed a crime (legal or moral) for having seen it.
A woman may suddenly remember a comment she made to a colleague last year and wonder if it could have been perceived as racially insensitive, then get stuck endlessly seeking reassurance about it from friends and the internet.
A mom may engage in endless mental rituals going back and forth between self-criticism and rationalization over having let her child hear a song with age-inappropriate lyrics.
A teen may step in a parking lot puddle and spend days crying, concerned that she might have tracked something harmful into the house that could harm her pet.
A man may suddenly remember a time his former girlfriend turned down a sexual gesture and spend every waking moment trying to remember if he coerced her in any way, including scouring the internet for any potential condemning references from that time period.
A young athlete may have a thought about his competitor getting injured and become consumed with guilt as he racks his brain for certainty that he would never really want that to happen.
These are just a few examples of how OCD can work its way into the moral universe. If it’s not your obsession, it can just look like taking oneself too seriously. But if it is your obsession, something as subtle as a sliver of doubt about moral intention can make it seem like your life is on the line. Nothing could seem more important than this. After all, don’t we all want to know in the end that we were one of the good ones?
In the previous installment of this series on Moral Scrupulosity OCD, we defined many of the ways it manifests and how it can be treated with exposure with response prevention (ERP). Let’s take a look now at the roles played by mindfulness, cognitive therapy, and self-compassion.
Can’t Do Anything Immoral If I Just Sit Here and Watch, Right?
The most important thing to understand about mindfulness is that it is an invitation to delineate between what is real and what is a story. To be mindful is to report objectively on the items that arise in consciousness. For example, right now you are absolutely, 100% definitely, without a question experiencing the words in front of you. They are simply there, in your field of vision. What they mean, well, that’s a story. It could be a true story, or could be fiction, but nonetheless the story is not objectively there. Just a bunch of thoughts. You are also feeling whatever you’re feeling in your body, hearing whatever sounds are available to hear, and you may be tasting something or smelling something as well.
Besides your five senses, you are aware of the presence of some thoughts. These thoughts are definitely occurring. But how are they any different than the visual of these words or the other information coming in through your other senses? They all land in the same place, your awareness. To be mindful of your thoughts is to read them like you read this blog, a string of words that you make meaning from. But they are not born with that meaning. If you can’t read, these words don’t make any sense to you.
When we lose sight of thoughts as thoughts and start to get lost in a web of stories, this is the OCD’s domain. “That was bad. I am bad. I shouldn’t be bad. I’m a failure. I am wrong. I hurt people. I am a deviant. I am dysfunctional. I must prove otherwise. I must be good.” These stories sweep you up and take you away from the present moment (where you would otherwise see them as just thoughts). Understanding that a story about your morality is not the same thing as an objective reality (you’re having thoughts and feelings, which aren’t the same thing as threats or facts) is key for liberating yourself from OCD.
But mindfulness isn’t easy. To “mind less” that these thoughts and feelings arise is to take a huge risk that you haven’t tried hard enough to be moral, that you could be wrong. Maybe this thought is the one you were supposed to wrestle to the ground and pummel! Being mindful is viewing OCD as simply a storyteller that weaves thoughts together to trick you into forgetting that they’re just thoughts, and viewing it this way is the ultimate exposure.
Everything I Do Is Wrong, Including Thinking About Being Wrong All the Time
It’s hard to discuss moral scrupulosity without getting into metacognitive and meta-metacognitive spirals. Moral scrupulosity is, by definition, very much about how we think about ourselves, so exploring whether we may be thinking about ourselves in unhealthy or unskillful ways necessarily involves still, well, thinking about ourselves. Even trying to navigate that sentence is a chore. Putting it more simply, moral scrupulosity is a form of OCD that emphasizes a fear of being immoral or morally contaminated. When we think “I am immoral” or “that was immoral”, we are making judgments about the self. We have a story about the self and if we think the story has been damaged, or poorly written, OCD tells us it needs a rewrite. But often we come to the conclusion that the story has been damaged because we are thinking unskillfully about our experiences. Put another way, we may be misinterpreting what we’re reading.
Cognitive therapy approaches to OCD involve stepping back and taking a look at the way we read our stories and then invites us to consider applying a more skillful, objective, or rational lens. It can very easily devolve into more ritualizing, more mental efforts to prove we’re good or disprove we’re bad. But done delicately, cognitive restructuring of moral scrupulosity obsessions can remind us that compulsions are not the moral mandates they appear as. Rather, compulsions are just recipes for short-term delusion and longer term suffering. Here are some unskillful thinking styles, or cognitive distortions, that apply to Moral Scrupulosity OCD.
Thought Action Fusion
A common cognitive error in all forms of OCD is to attribute powers to thoughts that they do not have and to confuse those fictional powers with actual actions or events. For example, I may have a thought about whether or not I committed an immoral act. Maybe I think I could have emotionally scarred someone by some action I remember taking in their presence. From there, it may splinter into one of two problems. I may come to believe that if I think about this action too much, it increases the likelihood that it caused harm. In other words, the more I think something, the greater the probability of its truth. Or, I may believe that the act of thinking it is, in and of itself, an immoral act (e.g. thinking about hurting someone is wrong and an act of oppression itself). In either case the problem is based on a confusion, or fusion, of thoughts and actions in the mind.
All-or-nothing thinking
Seeing the world in black and white is not seeing the world clearly. This is not an appeal to moral relativism, but to reality itself. Life is complicated and simplifying it into only two categories (the way OCD likes it), makes it too easy to slip into mindless compulsive reacting. In the world of moral scrupulosity, this means dividing the self into two categories of good and bad. If I do or think or intend for a bad thing, even for a second, even if based on a misunderstanding, then I am a bad person. If I can’t prove 100% that I am a good person, I must assume I am bad. To be sorta kinda ok on the moral front is unacceptable. Well, the truth is, good guys and bad guys make for decent 80’s cop movies, but not for much else.
Magnifying
If you have moral scrupulosity, making a big deal out of every real or imagined moral misstep doesn’t seem like magnifying. It seems like compensating for bad behavior. People with moral scrupulosity tend to purposely blow up their real and imagined transgressions as a form of compulsive reassurance that they are taking ownership of wrongdoing (and therefore must be supremely moral). The antidote to this is seeing things as they are in the moment (here he is with the mindfulness again). Maybe you made a mistake. Maybe you are having thoughts about having made a mistake. Maybe one choice wasn’t your most heroic. Working with that, the way things actually are, gives you a fighting chance against the OCD. Ballooning up uncertainty about your morals into giant acts of evil is just an invitation to do compulsions.
Discounting/disqualifying the positive
If you’re sitting tied to a post surrounded by angry torch-wielding locals who are shouting at you, then disregard this paragraph. If you’re just a person reading a blog about OCD, then the universe is telling you a lot already about your moral worth. The universe is often telling us that everything is fine. It’s this disconnect between the appearance of things being fine and the brutal intrusive thoughts and emotions telling us we’re bad people that makes OCD so frustrating. Rather than trying to push away information that contradicts your OCD, a better strategy would be to accept it when you see it.
Tunnel vision/selective abstraction
Like disqualifying the positive, tunnel vision is a way of thinking that emboldens our obsessions. It says that the things we notice in the universe that could be related to our obsessions are proof of the importance of those obsessions. So if you see moral quandaries everywhere, you determine this must mean moral failing on your part. How easily we forget that we notice what we look for and we look for what we are obsessed with!
Emotional reasoning
People with all forms of OCD often wake up with and walk around with a lot of free-floating guilt and shame. Since moral scrupulosity is, by definition, an obsession with self-worth or “goodness”, it should come as no surprise that OCD promotes these painful feelings as bait to start doing compulsions. Guilt proves nothing. Recognizing that feelings are not reliable evidence of facts can take some of the power away from OCD’s claim.
Overestimation of responsibility
Moral scrupulosity OCD will tell you that your awareness of a potential moral quandary is the same thing as signing a contract to solve the moral quandary. This not only applies to yourself and the all of the compulsions it tells you to do to prove that you are morally clean, but often to others as well. For example, you may feel that someone else’s moral misstep (real or imagined) is up to you and you alone to undo or stop from being repeated. This can lead to over-controlling behavior towards others that can appear nosy or pushy, when in fact it is just driven by a fear of your own guilt. It can also lead to extreme safety measures, such as removing objects from a street that your OCD says might be distracting to a driver and leaving you responsible for their potential accident.
Shoulding
You should not use should and if you do, you should know that shoulding is bad and you should have known better, shouldn’t you have? Got it? Good. People with moral scrupulosity often feel like slaves to the word “should.” Sometimes it can be subtle, like, I should recycle, and then the OCD promotes doubt about the efficiency or quality of your recycling efforts (for the record, I literally put things in recycling bins that I think should be recyclable, even when my confidence level on this is low). It can also be philosophical, like, I should not think harmful thoughts. Most notably, should statements can be meta or abstract, as in, I should always be certain whether or not I have been moral. It is impossible to challenge one’s distorted attachment to “should-thinking” without doing ERP. By definition, being flexible in response to “should” statements is to admit to something different from (or as OCD would frame it, less than) perfectly concrete moral reasoning.
Stop Being Such a Wimp and Be More Self-Compassionate
All of this risk-taking with moral obsessions can be an invitation to self-criticize. It is inevitable that challenging the way in which we think, even if for the wiser, leaves us vulnerable to accusations of being “bad” (whatever the OCD says that means). If our efforts to be perfectly certain about morality cause us to be compulsive, and ERP asks us to scale back that behavior, then we are going to feel, well, less moral in a way. We may try to compensate for this by engaging in self-punishment, being extra unkind to ourselves to make sure we aren’t getting away with anything. If I can at least prove that I feel bad (i.e. guilty, disgusted, self-hating) about real and imagined moral failings, then I am at least somewhat liberated from worrying about being immoral. Put simply, self-criticism is a compulsion. It often gets overlooked because we tend to think of compulsions as feeling good. In reality, compulsions simply feel better than what we imagine the alternative to be and beating yourself up sounds better than taking the risk of finding out you’re a bad person later. If only it worked.
Self-compassion isn’t for the faint of heart. It’s pretty hard exposure work, if done honestly, and takes great courage to pull off. Shala Nicely and I discuss in Everyday Mindfulness for OCD how to effectively use self-compassion as a tool to push back against OCD’s brutality. We took some inspiration here from Kristin Neff’s work on the subject (see her book Self-Compassion). Neff identifies mindfulness, common humanity, and self-kindness as three aspects of treating yourself the way you would hope to treat others. Here’s how you can think of them in terms of moral scrupulosity:
Mindfulness
I am thinking I did the wrong thing and feeling guilty. This is a mindful statement because it observes what is going on without adding additional narratives or judgments to it. Remember, mindfulness simply means observing things how they are in the present. Note that the statement does not include stories such as “I am a failure at being human.” It’s not just that this statement would be unkind, but that it is fundamentally dishonest. “Failure” is ill-defined and in reality you don’t know for certain whether or not you meet it. You think you might and you feel like you do and these thoughts and feelings are what you need to acknowledge.
Common humanity
Many people worry about doing the right thing and feel uncomfortable with uncertainty about this. This statement acknowledges simply that what you are feeling is not unique to you, despite OCD’s emphasis to the contrary. Many people do in fact worry about the same issues that those with Moral Scrupulosity OCD worry about, just not to the point of debilitation. Let go of the need to isolate yourself emotionally and instead let yourself recognize that whatever you are feeling is what humans feel. This is an important antidote to self-criticism.
Self-kindness
I’m trying my hardest not to seek reassurance or do other compulsions right now. I can give myself permission not to have all the answers and take the risk of doing my ERP homework. All you’re doing here is pointing out what you’re doing right. It could be really small, so long as it’s honest. Then, you just have to identify something that stands a chance at being useful, rather than continuing to beat yourself up.
Self-compassion is not about letting yourself off the hook or being in denial of your character flaws. It really is an exposure when you have moral scrupulosity. It entails taking the risk of being brutally and objectively honest about your experience without the compulsive or abusive commentary. It involves taking a huge risk of treating yourself as if your worth were not open to debate, skipping an opportunity to judge yourself so that you can make healthy self-serving choices in the present moment. Pretty scary stuff considering that it opens you up to the risk of remaining uncertain about your obsessions.
If treating yourself badly proved you were good and proving you’re good freed you from your OCD, I’d be all for it. Have at it. I’m awful, you’re awful, we’re all just total losers with nothing to offer! The problem is, aside from this statement being obvious nonsense, it just doesn’t treat the OCD. It’s OCD trickery. Instead of beating yourself up, better to use CBT to kick the OCD where it counts.
In the next installment of this blog series, we’ll take a deeper look at some of the new and exciting ways we come up with to feel bad about ourselves. Huzzah! More to the point, we’ll examine further how CBT can help you gain mastery over Moral Scrupulosity OCD.
Click Here to read Moral Scrupulosity OCD: Part One
Jon Hershfield, MFT is a psychotherapist in private practice and director of The OCD and Anxiety Center of Greater Baltimore. Follow him on Twitter and Facebook.
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October 12, 2018
10 Mistakes First Time Home Buyers Need to Avoid
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The New Normal In Client Services
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September 20, 2018
Jon on Retreat: Notes From Three Days of Silent Meditation
Mindfulness, or learning to view thoughts and feelings as observable phenomena instead of “the truth” or “threats,” has been instrumental in my journey through OCD. But it was only in the last five years or so that I really started meditating. This was spurred in part by the fact that the $200 I cleverly spent on the lifetime membership to the new Headspace app ended up being 200 euros. Oops. But since it felt like something I really had to get my money’s worth from, I used it often.
The link between meditation and being a generally more mindful person revealed itself gradually over the years, just enough to keep me interested. Just as articulating my experience of CBT in online support groups led me to become a CBT therapist, articulating my understanding of mindfulness to my clients with OCD helped me as much as them. But it recently occurred to me that I was essentially bragging about knowing something amazing I had only just scratched the surface of. Dan Harris, in his charming book 10% Happier, would eventually plant the seed in my head that there was this thing called an intensive meditation retreat, where “serious” meditators went to train their minds. If that skeptic could do it, then so could I.
And so I found myself at the Insight Meditation Society (IMS) in Barre, MA (pronounced like the Manilow, not like the pub), attending the Discovering Freedom Labor Day Meditation Weekend led by Anushka Fernandopulle and Pascal Auclair. It struck me, in the few weeks leading up to the event, that I was way in over my head. Three days with no phone, no social media, no television, no talking, no music, no reading, no writing, no working, no meat, no family members or friends, and no real sense that I know what I’m doing. Two weeks before the retreat, I started training for the 3-day event like a marathon, increasing my usual 10-20 minute meditation practice to 30-45 minutes a day.
Armed with the knowledge that I could do at least that, I carefully followed the IMS’s detailed instructions of what to bring, with one notable exception – a wristwatch. I don’t own one for the same reason I don’t carry a calculator around. I have a smartphone. As I arrived at BWI airport, I started to obsess that, without my phone, the lack of time awareness could make me go insane. The only options at the duty free store were a bright pink jewel-bedazzled $30 watch made for an adolescent girl or a $250 one clearly made for an alpha male investment banker. I balked, figuring I could try again at the airport in Boston. There again I had no luck, finding only a $400 Apple watch that would surely be against the retreat rules. So I would go into the wilderness, with no sense of time.
Game of Thrones
When I arrived, I was greeted by friendly volunteers who checked my name off the list and invited me to claim my spot in the meditation hall. Off to the left, the foyer gives way to a large open space with mats filling the center, chairs along the sides and back, and an altar to Buddha in the front. Business in the front, party in the back, or the feng shui equivalent of a mullet. My knees do not allow for long periods of floor-sitting, so I always meditate in a chair. From a large collection of pillows, blankets, cushions, zafus and so forth, I chose a lumbar supporting cushion and claimed my chair.
I’m used to just using a pillow to support my lower back in my office chair, so I was very impressed with myself finding a lumbar supporting cushion that would give me perfect posture during the retreat. But after a few sittings, my back starting to throb terribly. I moved the cushion up and down several times, put an extra cushion in front of it, then a rolled up blanket under it, then another rolled up blanket on top of that, finding myself nearly pushed off the chair with four different “supporting” strategies behind me in the end. On the last day, I just used the chair as a chair. No pain. Simplicity wins again.
After claiming my meditation throne, I was instructed to go finish the registration process. This began with filling out a few health waivers and confessing my history of mental illness, giving them permission to politely ask me to leave if I completely lose it. Next I was asked to sign up for my yogi (meaning meditator) job. To keep the staff needs low and to add some variety to the meditative practice, retreatants are asked to spend about an hour a day maintaining the place. I leapt at the opportunity to do the dinner dishes because I’m terrible at other forms of cleaning and I (correctly) suspected this would be an adventure. Later that evening myself and another retreatant were trained in operating the industrial dishwasher, wherein my job was to place a tray full of dirty dishes inside, pull the lever, let the machine scare the germs away in 90 seconds or less, and then my partner would put the clean dishes back where they belong. So each dinner shift, I would finish eating early on, meet my partner in the back, and challenge myself to clean the dishes as quickly as they came back. Maybe it wasn’t my most mindful approach, competitive dishwashing, but I felt completely connected to what I was doing, and I have never felt more proud of pretending to have a job.
After registration, we were given a brief tour of the compound, the different dormitories, offices, meditation rooms, restrooms and so on. This must be an interesting place for someone with contamination OCD. Every bathroom is equipped with signs extolling the virtues of handwashing and the role it plays in responsibly avoiding the harming others with your nasty germs. Hand sanitizer can be found nearly every ten feet. Notably, this emphasis on hand washing comes with no sense of irony that we are all spending the majority of our time walking around barefoot, and sharing meditation mats and blankets with abandon.
Try Not to Murder Anyone for a Whole 3-Day Weekend
The first evening all 100 of us met in the meditation hall and listened to our teachers explain some of the Buddhist precepts (or guidelines) we were going to adopt for the next few days.
No harming or killing anyone, ok? Or anything, if you can avoid it. Even insects. The window sills boasted cups with the words “insect relocation device” written on them to encourage you to gently release bugs back into the wild.
No stealing. More specifically, no taking anything that isn’t freely given, including people’s attention.
No sexual misconduct. Keep your hands to yourselves. Actually, keep your hands off yourselves too while you’re at it.
No using of words to harm others, such as lying or gossip. This one should be easy because, no talking.
No getting intoxicated. This is considered a moral precept because of the carelessness it could lead to in the other precepts. But really, being intoxicated in this environment would be awful anyway and really defeat the purpose.
I think any reasonable person could get behind these moral guidelines, from any religious or cultural background.
We also learned about the “noble silence” we were about to adopt. There would be no talking, no using of phones, no reading or writing, and notably, no other attempts to communicate with one another. Sustained eye contact or big “wassaaaap” and “how you doin’?” facial expressions are, um, frowned upon. The reasoning for this is interesting. It’s not, as I had assumed, just about keeping your own mind settled. It’s actually a gift to the other retreatants to whom your attempts to get attention may be a distraction from their own process. In other words, trying to interact with someone means placing on them the burden of interacting with you while they are clearly here to learn to better interact with their own mind. For the first day, this results in the illusion that everyone is sort of pissed off or depressed. Nobody really looks at you and if they do, they quickly find something else to look at. By the second day, this story about them fades away and the experience is, as the teachers had implied, one of gratitude for the opportunity to truly be alone without also being isolated or rejected.
We were informed that our phones would be turned in the next morning as part of a renunciation ritual. I desperately wanted to turn my phone in right then and there, rip off the bandaid, but I also wanted to participate in the ceremony. I had already turned it off, shortly after texting my wife an ominous final “love you, singing off, I mean signing off, damn you autocrrect.” Now the challenge was spending the whole night pretending the device didn’t exist. Noble silence begins now.
I had my own room, which included a twin bed, a closet, a sink, a chair and an alarm clock. For the first time in, let’s be honest, probably forever, I brushed my teeth, said goodnight to nobody, lay flat on my back and waited for sleep to take me. It was 9:30.
“Waking Up” with Jon Hershfield
I got up around 6am, which I would each morning, before the 6:30 alarm. This gave me enough time to get to the meditation hall and show everyone how cool I am by being one of the elite few choosing to squeeze in a few minutes of non-mandatory meditation before breakfast. I was the only o— oh, look, there’s about 40 people.
Then we got in line for breakfast, a buffet style vegetarian smorgasbord of oatmeal and fixins. Without the distraction of my phone or any form of communication with others, directly or indirectly, I immediately became aware of certain tendencies. For example, in a buffet situation, I tend to get one of everything out of fear of wanting one of anything, only to have a dish full of everything that more or less tastes like nothing I want. That being said, the food was wonderful, each meal, and not just because food of any kind is an assault on the senses when you spend most of your time meditating. It really was good. Also good, eating a meal without talking to anyone and without feeling like you should be.
Despite being very structured, the rest of the retreat is somewhat of a blur. It’s a good thing that it’s a blur. At some point it occurred to me that I would probably write this blog. The moment that happened, the idea of the blog itself became a distraction. It was like carrying a camera around with the thought, “Oh, I should remember this moment so I can experience it later.” The amount of time I already spend doing that dance in my head is absurd, so I actively chose not to do it this weekend. I chose not to note or remember what would be good to write about. The remainder of this blog is a combination of what I remember anyway and what I can translate, which may be different from what actually happened. Here’s what stuck.
Sitting Still and Still Sitting
We all ceremoniously offered up our phones after some wise words from our teachers about how phones are the destroyers of mindfulness. As I dropped my phone into the cauldron, all of the crisis client calls I’d be missing, all the child health emergencies that could come up, and all of the lost “likes” on my latest published work (a picture of my cats) flashed through my mind. They all seemed equally important. But with this came an immediate sense of relief. I get the same feeling when I’m in a plane taking off. It’s all up to the pilot now, nothing for me to screw up or fix.
The day is made up mostly of alternating 30-60 minute sessions of sitting meditation and walking meditation, broken only by meals and a morning “work” hour (which I avoided by pulling dishwasher duty after dinner). The lunch break is long enough that there is time to go rest or explore the wooded trails after you eat. As it turned out, the only function a watch would have served on this trip is to make me wonder what time it was. Each session starts and begins with a bell (rung dutifully by those assigned to race around the compound ringing bells at the right time). I felt grateful for being watchless.
Several of the sitting meditations included teacher instruction, so the mind is really set in listening mode for at least half of some of the sessions. In other words, it was rare that I had to spend an entire hour just listening to the sound of my own inner symphony. The teachers were great, always making the abstract more concrete and the holy more down-to-earth. It was nice to hear a voice, any voice, and it was also nice to hear gentle laughter from my fellow retreatants. The teachings all had the same distinct quality, that they were all made up of things I already knew but hadn’t been able to see clearly. I never had to accept a notion that seemed like a lie, that if only I could get past this one lie, I’d find all this faith and ecstasy. To the contrary, it all made sense in a way that felt like I had just forgotten certain truths and the teachers were there to remind me.
Walking and Ending the Civil War
Walking meditation was something I had only tried once before for a few minutes. I remember at one point upon arrival on the first day noticing someone walking extraordinarily slow in the walkway in front of the building. He would step, pause, lift his heel, pause, lift the whole foot, step, pause again. I thought, “he really isn’t sure where he’s going.” As it turns out, this is hardly different from traditional meditating. Instead of focusing on the breath, you simply rest your attention on the sensation of walking. It’s pretty boring stuff, until it suddenly isn’t, and you realize that everything you’ve been hearing about mindfulness isn’t just true because you want it to be, but because it actually makes sense.
The feeling of my foot pushing down on the ground is actually happening, and this is distinctly different from a story in my head. The mind wanders, as minds do, and you note the wandering and return to the walking, but as you continue this practice, it becomes extraordinarily clear that there is a difference between an experience (what is happening now) and a narrative (what you think or believe about yourself, the past, and the future). The implications for this in regards to OCD are somewhat obvious. OCD is all about stories, what could have happened or might happen, and our discomfort with the associated uncertainty. Getting a glimpse of what it’s like to actually be free of stories is what it’s like to get a glimpse of being truly free from OCD.
This kind of awareness took a while to reveal itself. For much of the first day, my mind was consumed by thoughts about relationships. My relationship to my wife, to my parents, to people in general, to work, to OCD, to my vices and devices. Void of anything to distract myself other than the five senses in front of me and the awareness of my consciousness, all of these stories about these relationships just hung there like a fog. Leaving it there, rather than investing in analysis or other strategies to change it, allowed it to sort of burn off after a while. It’s not that the stories became false or fictional, just that they weren’t really what they claimed to be. The only metaphor I can think of here would be that of a book. I can hold a book in my hand and say “this is the story of the Civil War” and regardless of whether it is an accurate depiction of the war, it’s still not really the war. It’s still a book. I can’t hold “the war” or show it to you because it’s not really there.
By the middle of the second day, it was actually getting fun to witness myself slipping into stories about some of the most awful things I have grappled with in life and then slip right out of them the moment I realize what I’m doing. I thought the name of the retreat, Discovering Freedom, a bit pretentious at first. The Buddhists are always going on about liberation and freeing yourself and becoming non-attached. Am I a slave? A balloon?? Well, as it turns out, being a witness to the illusion actually is freeing. I could see the narratives that have always caused me suffering and I could see them as narratives. This didn’t stop them from being painful or reveal them even to be untrue. It gave me the freedom to simply know them instead of being obliged to fix them. Again, like knowing you’ve read a book without having to be its editor. It doesn’t matter if the contents of the book are true or false. A book about a thing is not the thing itself.
In OCD, when we become aware of intrusive thoughts, we often fail to see them as stories; that much is obvious. But even when we do understand them to be stories, the disorder still makes us feel as if there is a mandate (often a moral one) to investigate these stories. There are times where we respond to stories like they are true, just in case, and doing so makes sense in context. After all, if I wake up to red fluid coming out of my ears, I will go to the doctor even though the thought “I have an ear infection” is still technically just a story in that moment. If I have red fluid coming out of my ears and I’m also dressed as a zombie for Halloween, I will respond differently.
OCD warps our interpretation of stories to make us assume that every line from a story that scares us is a reason to respond. For example, if you have Harm OCD and get an intrusive thought about stabbing someone, whether you think this is a story or not, you are likely to think you need to do something about it. This is because, while you are distracted with the story of stabbing, you miss that this moral mandate to get certain that the story is untrue is also a story. This is the disorder in action. It creates a blind spot for recognizing when the urge to respond compulsively to your stories is also just another story. I believe mindfulness is the key to reducing, maybe even removing, that blind spot. (exposure and response prevention is a useful way to get you to that mindfulness, but that’s for another blog)
Most of What I Really Have to Say Are Expletives
I spoke three times during the noble silence, all comments to myself, alone, and loudly. The first two times involved walking the trails. Each day there was at least an hour of undefined time where you could nap, meditate, or take your chances walking the trails cut out of the Massachusetts woods. Plenty of signs are posted in the foyer to alert you to the dangers of Lyme disease and the potential for encounters with black bears. Also, you are strongly encouraged to only walk alone. Walking in pairs could only have two potential outcomes, breaking noble silence or falling in love, both best avoided here. Good luck reconciling walking alone and being mindful of, um… bears?
Anyway, the first time I spoke, I was reading a map posted on a tree detailing the multiple paths I could take. When choosing left or right, I concluded that going off to the right would be a shorter and less anxiety-producing trip. “Yeah, let’s go that way,” I stated with loud conviction. “Oh, damn it, I spoke. Oh, I spoke that too. Shh.” Who was I talking to? The self that I was walking with, presumably.
Later on, I felt a stinging sensation on my leg and slapped it, revealing the remains of an exploded mosquito. I recalled my commitment to the basic precepts, no talking, no sex, no stealing, and no killing of any living thing. “F*ck.” That’s two. For a moment thereafter I wondered about the literal blood on my hands and whether it was mosquito blood, my blood, the blood of a disease-infected person it had been feasting on before, or some cocktail of the three. I decided to let that story go and head back to the compound before being eaten by a bear.
The third and last time I broke my vow of noble silence, was actually in some way a spiritual awakening. On the second day of the retreat, I had started to grow weary of walking meditation in a room full of people. The big toe on my left foot kept making a loud clicking sound with every step, which made me self-conscious around other meditators. After several sessions in the walking meditation room by the main hall, I decided to try the practice outside, but the mosquitos were relentless. There was plenty of bug spray available, but so much attention is paid there to trying not to offend or aggravate the smell sensitivities of fellow retreatants, and I didn’t feel like spraying myself and then having to shower and change my clothes. So I began exploring the building.
I came across a stairwell I hadn’t seen before and, lo and behold, a sign pointing down the stairs indicated there was another walking meditation room. I was somewhat concerned I didn’t belong there, just because it wasn’t pointed out in the initial orientation, but it all looked legit. I opened the door at the bottom of the stairs and it revealed a simple rectangular space, soft light emanating from the high windows on one side. It reminded me of the sort of space an acting or dance class might have been given, but without any mirrors. Off to one end, there was an absolutely huge and stunning statue of the Buddha with a gentle glowing light fixture above, giving him a haunting spiritual aura. “Hoooooly sh*t.” Three strikes and I’m in?
I would spend probably 8 hours over the next two days doing walking meditation in this room in complete solitude. Just me walking towards the Buddha, me walking away, and over and over again in slow motion, me and my weird toe-clicking sounds. This is where I first understood that all of the things I was thinking about were distinctively less “real” than the sensation of my foot on the ground, or the image of the Buddha in front of me, or the musty smell of the wooden floor. The blurry line between reality and illusion suddenly seemed more obvious. With some irony, this became “my” walking meditation room so much so that when the teachers reminded us on the last day to explore other meditation rooms, I almost spoke up to discourage the idea. With even further irony, three or four others did discover the room on the last day, but by this time, I didn’t think of my walking noises as anybody’s problem or myself as owning anything. It was probably the most freeing walking session of the retreat and the first moment it occurred to me, I didn’t want it to end.
All Good Things Come to Wherever You Are
But it did end. I got my phone back and it felt heavy in my hand. It felt good to be present and almost dangerous to plug back in to “real” life. The sense of losing the freedom I found on retreat and the sense of happy anticipation of seeing my family sort of cancelled each other out, but it felt okay. I was in some kind of zone and, since I arrived home, I have mostly stayed in that zone. Even at the airport I became my own pet peeve, the guy walking to his destination like he doesn’t have to be anywhere quickly.
Most notably, I find myself letting go of distractions differently. Instead of thinking “I should put my phone down, stop checking my email, and spend time with my family,” I am thinking “I don’t desire my phone right now.” and turn it off when I get home. Instead of thinking “I should stop ruminating on this obsession,” I am thinking “I don’t need to do this right now” and find myself exploring what I was doing before I wandered off. This isn’t new practice for me, but it is clearly less forced. In fact, this is true of many of the “devices” or strategies I have habitually used to get away from the present. I can’t help but recognize the temporary nature of distracted pleasures and the predictable disappointments that come with them. Compulsions feel like distractions and most distractions feel like wasted opportunities to be present. I don’t mean that I stopped doing things like watching tv. Jesus, season two of Ozark is on. But I watch it without my phone in hand and watch myself slip in and out of the story in a way that feels oddly graceful.
Maybe this feeling of being ok in the moment and viewing my stories as stories won’t last. Maybe I’ll just snap back into place, back to a less mindful state. Or maybe living mindfully is just another “thing” I’ve become compulsively attached to as the “thing” that is supposed to fix everything. Or maybe that too is just another story. One thing is certain. Something has clicked besides my weird toe. It’s like years of priming the pump with meditation, and reading, writing, and teaching mindfulness have culminated in one great push of the lever and (perhaps) finally the generator is on. I have no idea what this makes me capable of now, but so far I am enjoying the ride.
The post Jon on Retreat: Notes From Three Days of Silent Meditation appeared first on OCD & Anxiety Center of Baltimore | Jon Hershfield, MFT.
July 14, 2018
Shedding Light on Health Anxiety OCD
Currently you may only know the suffering associated with Health Anxiety OCD, but through the right treatment, there is hope of learning to appreciate the way your mind works.
One of the things I find most heartbreaking about working with some of my OCD clients is that the disorder has ripped from them that which they treasure most and in turn engendered the very life they fear. In other words, it makes you become what you fear, just not in the way you’d expect. Those with Harm OCD may fear being rejected after hurting someone, but then they isolate themselves from their families. Those with Pedophile OCD may give up being a parent so there is no chance they will molest their child, but then they live a life not feeling safe around children. Those with Health Anxiety OCD may worry that unidentified or untreated illness will rob them of a fulfilling life, but then they miss out on enjoying the life they always dreamed about having by devoting all their attention to trying to be sure they are not ill. Regardless of the form OCD takes, OCD is the dictator who declares the lengths that must be followed to obtain 100 percent certainty and just as you begin to think you’ve appeased him… the dictator changes the rules.
Understanding Health Anxiety OCD
Regardless of whether we call it Health Anxiety OCD, Hypochondriasis, Illness Anxiety Disorder or Somatic Symptom Disorder, this content area is often misunderstood both in the medical profession and the mental health field. Some of the confusion arises from failing to understand that the diagnosis refers to a person that is chronically anxious about their health, not about whether they are actually sick or not. The fact is, one can be sick and have Health Anxiety OCD.
As with all content areas of OCD the real problem is not the content of the obsession, but the process of how you relate to and respond to it. Specifically, the problem is believing that you have to do compulsions in the effort to obtain certainty your fear is untrue. These failed efforts to be certain about one’s health ultimately lead to feeling less certain and more afraid. This being said, the content of all OCD sufferers’ obsessive thoughts always feels and seems important, and this sense of urgency about it distracts from recognizing the process problem. Living with Health Anxiety OCD can feel like you are living on borrowed time, which makes it nearly impossible to enjoy anything. Instead you feel driven to escape what could be a potential death sentence or avert some other tragic misfortune. What’s worse, it feels like you alone are responsible for carrying out this mission.
I remember as a child asking my mom what she was always so afraid of, and she said that she was afraid that she would be sick, and that it would be her fault for not being vigilant about watching for signs and symptoms. The look on her face was one of terror and bewilderment as she told me how unbearable it would be to find out she’s sick and to know that it would be all her fault for not having caught it sooner. As a child this made no sense to me but now, as an adult who has lived with OCD (and now specializes in the treatment of OCD) I understand that the terror and fear she felt was real. Her “fight or flight” system had signaled an emergency which she did not know was a false alarm. My mother was afraid of being sick, and everything that comes with being sick, but what really tormented her was the thought that she would be responsible for getting sick due to her failure to have checked enough.
Feared Consequences in Health Anxiety OCD
Feared consequences typically associated with Health Anxiety OCD include fear of dying or suffering from an illness of course, but also fear of permanent suffering, both mentally and physically, fear of abandoning your family because you didn’t take care of yourself, fear of never getting an accurate diagnosis and never finding treatment for your symptoms (real or imagined). This often includes intense pressure not only to figure out what is wrong with you, but also to be sure you are receiving the “right” treatment, for which you also take full responsibility. It is important to recognize when hyper-responsibility is playing a role in your health anxiety, so it can be targeted effectively during treatment.
What Health Anxiety OCD Makes You Feel Responsible For
Here are some ways OCD uses the fear of being irresponsible to keep you stuck in health anxiety.
Responsibility for seeking a diagnosis
What if I am ill but no one can figure it out because there isn’t a name for it?
What if this doctor read the results of the tests wrong?
How do I know that I am not developing an illness that has not been detected?
What if my failure to find an answer leads to endless suffering due to my awareness of symptoms
Responsibility for being vigilant about monitoring symptoms
What if this sensation or symptom is a sign of cancer or a chronic illness?
If I don’t check for signs of illness it could end up being my fault for not checking.
Responsibility for avoiding the potential of contracting an illness
What if I should not have allowed myself to be around someone who appeared ill?
What if I have not paid close enough attention to something that could have gotten me ill?
Responsibility for inadvertently causing harm
What if I have an undetected illness and get someone else sick?
What if I am currently sick or get sick due to my own lack of vigilance?
Responsibility for reporting symptoms and sensations
What if I fail to describe my symptoms accurately which results in the wrong diagnosis?
What if I fail to recognize changes in my symptoms?
Common Compulsions in Health Anxiety OCD
It can be easy to miss when apparent efforts to responsibly take care of your health are actually compulsions that fuel your obsessive thinking. Here are some things to look out for:
Asking friends or family to examine you for signs of illness
Repeated visits to multiple doctors
Requests for unnecessary (and/or repeated) tests
Excessively checking your own body to look for new symptoms or changes in symptoms
Reassurance seeking from multiple sources (professional and non- professional)
Self-reassurance by reviewing behavior to make sure the right precautions were taken or repeating comforting advice already given
Excessive visits to the Emergency Room
Avoiding places where one might be exposed to germs or sick people (malls, doctor’s offices, grocery stores, etc.)
Avoiding objects imagined to cause illness (standing in front of the microwave, holding phone to one’s ear, anything sharp, anything with certain chemicals, etc.)
Neutralizing bad “sick thoughts” with good “healthy thoughts
The Google Problem
When I was a kid (yes, back then we used encyclopedias) whenever someone was anxious about a potential health concern we went to the bookshelf and consulted a very large medical book. While looking for reassurance from a medical book was still a compulsion which resulted in finding new possibilities and new questions, there was a limit to what information you would find. Plus, it took a fair amount of effort.
Today we have Google, a limitless source of information which can all be obtained with a click. For those with Health Anxiety OCD, google is often a source of great misery and suffering. It starts with OCD selling you the lie that you could have your answer if you just looked up this one thing and then you could put it aside and carry on with the rest of your day (wouldn’t that be glorious?). However, it never works out this way because with Health Anxiety OCD googling itself is a reassurance seeking compulsion which maintains the cycle of OCD. It does this by reinforcing the idea to your brain that not only is your health in question but that you better do something about it fast.
This is partly what makes Google so problematic because it offers health anxiety sufferers a promise of immediate answers and it never says “No, you have had enough, stop googling”. It feeds you possibility after possibility, mostly negative, which serves to keep you terrified, desperate and even more convinced than before that you are probably very ill. Unlike other addictions where there is an opportunity to pause prior to running out to make a purchase, Google is immediately and readily available at your fingertips. Googling is a common compulsion in many forms of OCD and is usually one of the first compulsions I work with my clients to reduce.
Case Examples
Debbie is a 27-year-old female who initially presented to her doctor with vaginal burning and was concerned she might have an infection! Debbie’s pap smear came back normal and she tested negative for any urinary tract bacterial infections. Debbie went home and was fine until she began to feel what seemed like the same sensation of burning she had 2 weeks prior. Debbie became fearful that maybe now she had an infection. Debbie returned to the doctor who again stated that Debbie did not have an infection and maybe she needed to drink more water. This went on for many months. Debbie began to go to different doctors due to feeling embarrassed about going back to the same doctor a second or third time. Debbie was constantly aware of the sensation of burning that seemed to get worse day by day. Debbie was plagued by the following thoughts: What if I have these symptoms forever? What if there is something wrong and nobody can figure it out? What if I have an STD that has been dormant for all these years? Debbie started to Google STD’s and began to worry that maybe she had undiagnosed HPV which could result in cervical cancer. Debbie began to wonder whether she had used protection with every sexual encounter. She began to Google information about how to know if you have HPV which only led her to more questions. She also examined herself daily to look for irritation or signs of an infection. Debbie knew she had OCD but this time her OCD had her focused on the (real) sensations that might indicate an illness instead of the familiar intolerance of uncertainty and discomfort.
Mark is a 52-year-old male who is preoccupied with several moles on his body. Mark has a family history of skin cancer. Mark was diligent with checking the moles on his body to make sure there weren’t any changes in shapes or sizes that could be a sign of melanoma. Every day after showering he would look over the moles before getting dressed. One day he had the thought “how will I know that it didn’t change, and I just didn’t notice” and “what if I have melanoma and it is my fault for not doing a better job of monitoring my body?” The more Mark looked at the moles the more confused he became and wondered what should a mole look like? Mark innocently looked on the internet searching “what does a healthy mole look like”? Mark was immediately bombarded with images of healthy and unhealthy moles. Mark began to frequent the doctor’s office and his dermatologist’s. Both doctors said Mark was fine, but as soon as he left the office he would be plagued by the thought “maybe he didn’t see the one I was talking about.” Mark stared at the moles to look for inconsistencies in shape and color and frequently asked his wife to examine his moles. He began to remember all those summer days in his teens where he had chosen not to wear sunscreen despite his mother’s warnings. Mark’s OCD had him focused on the belief that he was being responsible to monitor changes in his skin when in fact he was on a never-ending quest for certainty driven by an over-inflated sense of responsibility.
Inaccurate Beliefs Driving Health Anxiety
In treating any form of OCD, it is important to identify unhelpful ways of framing experiences that drive your belief system and perpetuate you engaging in compulsions. To assist with this process, I often like to talk about fun house mirrors and ask my clients what their experiences have been when looking at their reflection. Most of the time they respond by saying they looked fat and short or tall and skinny. I then discuss how if they believed what they saw, they may feel driven to start exercising, to drink daily milkshakes or maybe even to look for work in the circus. I use this to illustrate how mistaken beliefs (or cognitive distortions) drive OCD sufferers to engage in compulsions, leading to more uncertainty and misery.
Mistaken Belief: You can know the status of your health with absolute certainty: You can never know with 100 percent certainty that you are healthy. Chances are, if you suffer from health anxiety, you know the anguish of going to the doctor’s and immediately upon leaving the office thinking, “What if I didn’t explain my symptoms accurately? What if they misunderstood what I was saying? What if they missed something important?” The truth is that with being human we all run the risk of getting sick or having an illness pop up with no warning. I hate to say it, but we will all die and that may be the result of illness or of old age, but either way our choice is to enjoy our life being present for the things that matter or spend all our time trying to prevent illness and miss out on all the joy that can be found living in the moment.
Mistaken Belief: Symptoms and sensations indicate illness and always have a specific cause that can be determined: This is a fallacy. Sensations happen all the time for many reasons, including for no specific reason. Sometimes sensations and symptoms are related to a specific health concern, sometimes they are indicators of nothing. However, once they are noticed, focused on and resisted, they tend to become more prominent simply because of the hyper-focus on them. To convey this idea with my clients I sometimes like to ask them where they are itchy. At first, they look at me blankly, but then usually identify a place that is itchy. The idea being that when you scan your body for sensations and symptoms you will likely find them. Just because you are aware of these experiences does not mean they are necessarily important or dangerous.
Mistaken Belief: Having the perfect diagnosis will always lead to effective treatment and elimination of all symptoms: While often there are effective treatments for your symptoms, this is not always the case. There are some conditions that even when diagnosed treatment options are limited. This is especially true for some chronic conditions such as Inflammatory Bowel Disease, Headache Disorders and Musculoskeletal conditions like Fibromyalgia. Your OCD is misleading you to believe that having a diagnosis (i.e. “the Answer”) will lead to relief.
Mistaken Belief: You are responsible for taking all possible precautions to avoid illness. The reality is that if you took every precaution you could possibly take to prevent illness, you would never be able to leave your home or have anyone come to your home, including the mail carrier. Even then, you couldn’t be sure that you took all precautions to prevent illness. Most enjoyable things in life inherently come with some risk. If you get out of bed, your risk goes up. Stay in bed too long, and your risk goes up too. But your OCD, not restricted by reason, would have you believe that there is no amount of risk worth taking when it comes to your health.
Mindfulness and ERP for Health Anxiety OCD
Exposure and Response Prevention (ERP), simply put, is a process where you confront your fears about your health and refrain from doing compulsions. People often think of mindfulness and ERP as two separate strategies when in fact mindfulness is often a part of ERP. While doing exposure to your fear you are mindfully allowing yourself to both approach and remain in the presence of your fear and mindfully choosing not to engage in compulsions. The purpose of this exercise is to essentially retrain your brain to respond to the obsessive thoughts without doing compulsions which ultimately teaches your brain that these thoughts are irrelevant (or tolerable) and require no response.
Learning to respond differently to these thoughts ultimately results in accepting uncertainty about their meaning. This both reduces your anxiety about the thoughts and increases your willingness to feel whatever anxiety may remain.
Examples of Exposures for Health Anxiety OCD
Reading articles about people dying from diseases both common and uncommon
Watching movies or videos about someone with a terminal illness
Visiting hospitals, nursing homes, or places where you might fear acquiring an illness
Writing imaginal scripts about being chronically or terminally ill and the consequences that could arise from this
Writing imaginal scripts about failing to do enough to prevent an illness, failing to take enough precautions or perfectly follow medical advice
For any of the above approaches to work, they must be paired with resisting checking, comparing, reassurance-seeking or other compulsions. Making contracts/agreements with loved ones to help you resist reassurance-seeking can also be instrumental in your progress.
Mindful Awareness
With health anxiety, practicing mindful awareness is knowing that you tend to be aware of your body’s symptoms and sensations in every possible way and understanding that simply being aware doesn’t necessarily have to be experienced as aversive. The awareness is experienced as aversive often because of the meaning and judgement subscribed to the experience. Being mindful of physical symptoms and sensations means viewing them from a different standpoint.
I don’t know about you, but I never wake up being greeted by a host of positive thoughts about my day that inspire me to feel good. Instead my brain presents potential pitfalls and disastrous outcomes that if I spend much time thinking about will land me right back into bed. With mindful awareness I can just expect to have these thoughts when I wake up, and instead of trying to make them disappear I make a choice to note them as they arise and just allow myself to get up and move forward. Accepting the presence of unwanted thoughts does not mean accepting the content of the thought as being true.
For example, I just had the thought …what if I am brewing some kind of cancer at this very moment and am irresponsibly just sitting here doing nothing about it? I could respond by taking the thought as a message or warning of some kind and immediately contact my doctor or I can thank my brain for its creativity and continue to do what I value, which at this moment is to continue to treat and support those with OCD.
Standing Up for Yourself
Sometimes living with Health Anxiety OCD can feel like you are living in your own private hell that never seems to end. On top of the despair you may feel, your OCD condemns and berates you for all the ways you imagine you may have failed, which then leads you to feel more isolated and often depressed. From this standpoint it is difficult to feel motivated or even capable of doing what it requires to get better. This is where self-compassion can be especially helpful. At this point my clients frequently scowl because they assume I am referring to some kind of “give yourself a break type statement” which they often hate. However, self-compassion is simply about viewing yourself as a human being who has challenges like all other human beings. Self-compassion is a way of separating yourself from the nasty voice of OCD and allowing yourself to be honest about the situation without judgement and criticism. From this position you are better equipped to challenge your OCD and actively engage in treatment.
The good news is you are not alone. Currently you may only know the suffering associated with your health anxiety but through the right treatment, there is hope of learning to appreciate the way your mind works. You may even learn to laugh at the ridiculousness of some of the ideas your OCD has you focused on and you may begin to appreciate the creativity it affords you. Above all, you may get to truly enjoy the benefits of the good health your OCD is so protective of.
Molly Schiffer, LGPC is a psychotherapist specializing in OCD and related disorders at The OCD and Anxiety Center of Greater Baltimore.
The post Shedding Light on Health Anxiety OCD appeared first on OCD & Anxiety Center of Baltimore | Jon Hershfield, MFT.
Shedding Light on Health Anxiety OCD
One of the things I find most heartbreaking about working with some of my OCD clients is that the disorder has ripped from them that which they treasure most and in turn engendered the very life they fear. In other words, it makes you become what you fear, just not in the way you’d expect. Those with Harm OCD may fear being rejected after hurting someone, but then they isolate themselves from their families. Those with Pedophile OCD may give up being a parent so there is no chance they will molest their child, but then they live a life not feeling safe around children. Those with Health Anxiety OCD may worry that unidentified or untreated illness will rob them of a fulfilling life, but then they miss out on enjoying the life they always dreamed about having by devoting all their attention to trying to be sure they are not ill. Regardless of the form OCD takes, OCD is the dictator who declares the lengths that must be followed to obtain 100 percent certainty and just as you begin to think you’ve appeased him… the dictator changes the rules.
Understanding Health Anxiety OCD
Regardless of whether we call it Health Anxiety OCD, Hypochondriasis, Illness Anxiety Disorder or Somatic Symptom Disorder, this content area is often misunderstood both in the medical profession and the mental health field. Some of the confusion arises from failing to understand that the diagnosis refers to a person that is chronically anxious about their health, not about whether they are actually sick or not. The fact is, one can be sick and have Health Anxiety OCD.
As with all content areas of OCD the real problem is not the content of the obsession, but the process of how you relate to and respond to it. Specifically, the problem is believing that you have to do compulsions in the effort to obtain certainty your fear is untrue. These failed efforts to be certain about one’s health ultimately lead to feeling less certain and more afraid. This being said, the content of all OCD sufferers’ obsessive thoughts always feels and seems important, and this sense of urgency about it distracts from recognizing the process problem. Living with Health Anxiety OCD can feel like you are living on borrowed time, which makes it nearly impossible to enjoy anything. Instead you feel driven to escape what could be a potential death sentence or avert some other tragic misfortune. What’s worse, it feels like you alone are responsible for carrying out this mission.
I remember as a child asking my mom what she was always so afraid of, and she said that she was afraid that she would be sick, and that it would be her fault for not being vigilant about watching for signs and symptoms. The look on her face was one of terror and bewilderment as she told me how unbearable it would be to find out she’s sick and to know that it would be all her fault for not having caught it sooner. As a child this made no sense to me but now, as an adult who has lived with OCD (and now specializes in the treatment of OCD) I understand that the terror and fear she felt was real. Her “fight or flight” system had signaled an emergency which she did not know was a false alarm. My mother was afraid of being sick, and everything that comes with being sick, but what really tormented her was the thought that she would be responsible for getting sick due to her failure to have checked enough.
Feared Consequences in Health Anxiety OCD
Feared consequences typically associated with Health Anxiety OCD include fear of dying or suffering from an illness of course, but also fear of permanent suffering, both mentally and physically, fear of abandoning your family because you didn’t take care of yourself, fear of never getting an accurate diagnosis and never finding treatment for your symptoms (real or imagined). This often includes intense pressure not only to figure out what is wrong with you, but also to be sure you are receiving the “right” treatment, for which you also take full responsibility. It is important to recognize when hyper-responsibility is playing a role in your health anxiety, so it can be targeted effectively during treatment.
What Health Anxiety OCD Makes You Feel Responsible For
Here are some ways OCD uses the fear of being irresponsible to keep you stuck in health anxiety.
Responsibility for seeking a diagnosis
What if I am ill but no one can figure it out because there isn’t a name for it?
What if this doctor read the results of the tests wrong?
How do I know that I am not developing an illness that has not been detected?
What if my failure to find an answer leads to endless suffering due to my awareness of symptoms
Responsibility for being vigilant about monitoring symptoms
What if this sensation or symptom is a sign of cancer or a chronic illness?
If I don’t check for signs of illness it could end up being my fault for not checking.
Responsibility for avoiding the potential of contracting an illness
What if I should not have allowed myself to be around someone who appeared ill?
What if I have not paid close enough attention to something that could have gotten me ill?
Responsibility for inadvertently causing harm
What if I have an undetected illness and get someone else sick?
What if I am currently sick or get sick due to my own lack of vigilance?
Responsibility for reporting symptoms and sensations
What if I fail to describe my symptoms accurately which results in the wrong diagnosis?
What if I fail to recognize changes in my symptoms?
Common Compulsions in Health Anxiety OCD
It can be easy to miss when apparent efforts to responsibly take care of your health are actually compulsions that fuel your obsessive thinking. Here are some things to look out for:
Asking friends or family to examine you for signs of illness
Repeated visits to multiple doctors
Requests for unnecessary (and/or repeated) tests
Excessively checking your own body to look for new symptoms or changes in symptoms
Reassurance seeking from multiple sources (professional and non- professional)
Self-reassurance by reviewing behavior to make sure the right precautions were taken or repeating comforting advice already given
Excessive visits to the Emergency Room
Avoiding places where one might be exposed to germs or sick people (malls, doctor’s offices, grocery stores, etc.)
Avoiding objects imagined to cause illness (standing in front of the microwave, holding phone to one’s ear, anything sharp, anything with certain chemicals, etc.)
Neutralizing bad “sick thoughts” with good “healthy thoughts
The Google Problem
When I was a kid (yes, back then we used encyclopedias) whenever someone was anxious about a potential health concern we went to the bookshelf and consulted a very large medical book. While looking for reassurance from a medical book was still a compulsion which resulted in finding new possibilities and new questions, there was a limit to what information you would find. Plus, it took a fair amount of effort.
Today we have Google, a limitless source of information which can all be obtained with a click. For those with Health Anxiety OCD, google is often a source of great misery and suffering. It starts with OCD selling you the lie that you could have your answer if you just looked up this one thing and then you could put it aside and carry on with the rest of your day (wouldn’t that be glorious?). However, it never works out this way because with Health Anxiety OCD googling itself is a reassurance seeking compulsion which maintains the cycle of OCD. It does this by reinforcing the idea to your brain that not only is your health in question but that you better do something about it fast.
This is partly what makes Google so problematic because it offers health anxiety sufferers a promise of immediate answers and it never says “No, you have had enough, stop googling”. It feeds you possibility after possibility, mostly negative, which serves to keep you terrified, desperate and even more convinced than before that you are probably very ill. Unlike other addictions where there is an opportunity to pause prior to running out to make a purchase, Google is immediately and readily available at your fingertips. Googling is a common compulsion in many forms of OCD and is usually one of the first compulsions I work with my clients to reduce.
Case Examples
Debbie is a 27-year-old female who initially presented to her doctor with vaginal burning and was concerned she might have an infection! Debbie’s pap smear came back normal and she tested negative for any urinary tract bacterial infections. Debbie went home and was fine until she began to feel what seemed like the same sensation of burning she had 2 weeks prior. Debbie became fearful that maybe now she had an infection. Debbie returned to the doctor who again stated that Debbie did not have an infection and maybe she needed to drink more water. This went on for many months. Debbie began to go to different doctors due to feeling embarrassed about going back to the same doctor a second or third time. Debbie was constantly aware of the sensation of burning that seemed to get worse day by day. Debbie was plagued by the following thoughts: What if I have these symptoms forever? What if there is something wrong and nobody can figure it out? What if I have an STD that has been dormant for all these years? Debbie started to Google STD’s and began to worry that maybe she had undiagnosed HPV which could result in cervical cancer. Debbie began to wonder whether she had used protection with every sexual encounter. She began to Google information about how to know if you have HPV which only led her to more questions. She also examined herself daily to look for irritation or signs of an infection. Debbie knew she had OCD but this time her OCD had her focused on the (real) sensations that might indicate an illness instead of the familiar intolerance of uncertainty and discomfort.
Mark is a 52-year-old male who is preoccupied with several moles on his body. Mark has a family history of skin cancer. Mark was diligent with checking the moles on his body to make sure there weren’t any changes in shapes or sizes that could be a sign of melanoma. Every day after showering he would look over the moles before getting dressed. One day he had the thought “how will I know that it didn’t change, and I just didn’t notice” and “what if I have melanoma and it is my fault for not doing a better job of monitoring my body?” The more Mark looked at the moles the more confused he became and wondered what should a mole look like? Mark innocently looked on the internet searching “what does a healthy mole look like”? Mark was immediately bombarded with images of healthy and unhealthy moles. Mark began to frequent the doctor’s office and his dermatologist’s. Both doctors said Mark was fine, but as soon as he left the office he would be plagued by the thought “maybe he didn’t see the one I was talking about.” Mark stared at the moles to look for inconsistencies in shape and color and frequently asked his wife to examine his moles. He began to remember all those summer days in his teens where he had chosen not to wear sunscreen despite his mother’s warnings. Mark’s OCD had him focused on the belief that he was being responsible to monitor changes in his skin when in fact he was on a never-ending quest for certainty driven by an over-inflated sense of responsibility.
Inaccurate Beliefs Driving Health Anxiety
In treating any form of OCD, it is important to identify unhelpful ways of framing experiences that drive your belief system and perpetuate you engaging in compulsions. To assist with this process, I often like to talk about fun house mirrors and ask my clients what their experiences have been when looking at their reflection. Most of the time they respond by saying they looked fat and short or tall and skinny. I then discuss how if they believed what they saw, they may feel driven to start exercising, to drink daily milkshakes or maybe even to look for work in the circus. I use this to illustrate how mistaken beliefs (or cognitive distortions) drive OCD sufferers to engage in compulsions, leading to more uncertainty and misery.
Mistaken Belief: You can know the status of your health with absolute certainty: You can never know with 100 percent certainty that you are healthy. Chances are, if you suffer from health anxiety, you know the anguish of going to the doctor’s and immediately upon leaving the office thinking, “What if I didn’t explain my symptoms accurately? What if they misunderstood what I was saying? What if they missed something important?” The truth is that with being human we all run the risk of getting sick or having an illness pop up with no warning. I hate to say it, but we will all die and that may be the result of illness or of old age, but either way our choice is to enjoy our life being present for the things that matter or spend all our time trying to prevent illness and miss out on all the joy that can be found living in the moment.
Mistaken Belief: Symptoms and sensations indicate illness and always have a specific cause that can be determined: This is a fallacy. Sensations happen all the time for many reasons, including for no specific reason. Sometimes sensations and symptoms are related to a specific health concern, sometimes they are indicators of nothing. However, once they are noticed, focused on and resisted, they tend to become more prominent simply because of the hyper-focus on them. To convey this idea with my clients I sometimes like to ask them where they are itchy. At first, they look at me blankly, but then usually identify a place that is itchy. The idea being that when you scan your body for sensations and symptoms you will likely find them. Just because you are aware of these experiences does not mean they are necessarily important or dangerous.
Mistaken Belief: Having the perfect diagnosis will always lead to effective treatment and elimination of all symptoms: While often there are effective treatments for your symptoms, this is not always the case. There are some conditions that even when diagnosed treatment options are limited. This is especially true for some chronic conditions such as Inflammatory Bowel Disease, Headache Disorders and Musculoskeletal conditions like Fibromyalgia. Your OCD is misleading you to believe that having a diagnosis (i.e. “the Answer”) will lead to relief.
Mistaken Belief: You are responsible for taking all possible precautions to avoid illness. The reality is that if you took every precaution you could possibly take to prevent illness, you would never be able to leave your home or have anyone come to your home, including the mail carrier. Even then, you couldn’t be sure that you took all precautions to prevent illness. Most enjoyable things in life inherently come with some risk. If you get out of bed, your risk goes up. Stay in bed too long, and your risk goes up too. But your OCD, not restricted by reason, would have you believe that there is no amount of risk worth taking when it comes to your health.
Mindfulness and ERP for Health Anxiety OCD
Exposure and Response Prevention (ERP), simply put, is a process where you confront your fears about your health and refrain from doing compulsions. People often think of mindfulness and ERP as two separate strategies when in fact mindfulness is often a part of ERP. While doing exposure to your fear you are mindfully allowing yourself to both approach and remain in the presence of your fear and mindfully choosing not to engage in compulsions. The purpose of this exercise is to essentially retrain your brain to respond to the obsessive thoughts without doing compulsions which ultimately teaches your brain that these thoughts are irrelevant (or tolerable) and require no response.
Learning to respond differently to these thoughts ultimately results in accepting uncertainty about their meaning. This both reduces your anxiety about the thoughts and increases your willingness to feel whatever anxiety may remain.
Examples of Exposures for Health Anxiety OCD
Reading articles about people dying from diseases both common and uncommon
Watching movies or videos about someone with a terminal illness
Visiting hospitals, nursing homes, or places where you might fear acquiring an illness
Writing imaginal scripts about being chronically or terminally ill and the consequences that could arise from this
Writing imaginal scripts about failing to do enough to prevent an illness, failing to take enough precautions or perfectly follow medical advice
For any of the above approaches to work, they must be paired with resisting checking, comparing, reassurance-seeking or other compulsions. Making contracts/agreements with loved ones to help you resist reassurance-seeking can also be instrumental in your progress.
Mindful Awareness
With health anxiety, practicing mindful awareness is knowing that you tend to be aware of your body’s symptoms and sensations in every possible way and understanding that simply being aware doesn’t necessarily have to be experienced as aversive. The awareness is experienced as aversive often because of the meaning and judgement subscribed to the experience. Being mindful of physical symptoms and sensations means viewing them from a different standpoint.
I don’t know about you, but I never wake up being greeted by a host of positive thoughts about my day that inspire me to feel good. Instead my brain presents potential pitfalls and disastrous outcomes that if I spend much time thinking about will land me right back into bed. With mindful awareness I can just expect to have these thoughts when I wake up, and instead of trying to make them disappear I make a choice to note them as they arise and just allow myself to get up and move forward. Accepting the presence of unwanted thoughts does not mean accepting the content of the thought as being true.
For example, I just had the thought …what if I am brewing some kind of cancer at this very moment and am irresponsibly just sitting here doing nothing about it? I could respond by taking the thought as a message or warning of some kind and immediately contact my doctor or I can thank my brain for its creativity and continue to do what I value, which at this moment is to continue to treat and support those with OCD.
Standing Up for Yourself
Sometimes living with Health Anxiety OCD can feel like you are living in your own private hell that never seems to end. On top of the despair you may feel, your OCD condemns and berates you for all the ways you imagine you may have failed, which then leads you to feel more isolated and often depressed. From this standpoint it is difficult to feel motivated or even capable of doing what it requires to get better. This is where self-compassion can be especially helpful. At this point my clients frequently scowl because they assume I am referring to some kind of “give yourself a break type statement” which they often hate. However, self-compassion is simply about viewing yourself as a human being who has challenges like all other human beings. Self-compassion is a way of separating yourself from the nasty voice of OCD and allowing yourself to be honest about the situation without judgement and criticism. From this position you are better equipped to challenge your OCD and actively engage in treatment.
The good news is you are not alone. Currently you may only know the suffering associated with your health anxiety but through the right treatment, there is hope of learning to appreciate the way your mind works. You may even learn to laugh at the ridiculousness of some of the ideas your OCD has you focused on and you may begin to appreciate the creativity it affords you. Above all, you may get to truly enjoy the benefits of the good health your OCD is so protective of.
Molly Schiffer, LGPC is a psychotherapist specializing in OCD and related disorders at The OCD and Anxiety Center of Greater Baltimore.
July 1, 2018
Moral Scrupulosity OCD: Part One
It can be argued that many forms of OCD come down to a fear that lack of vigilance could lead to a loss of identity. One with Harm OCD may worry that failure to catch that one impulse could lead to spontaneous discovery that he/she is a violent or harmful person. One with sexual orientation obsessions may be excessively concerned that this one thought or sensation left up to uncertainty could reveal the discovery of gay denial. Choosing to take the risk of accepting you might have touched your shoe but just aren’t going to pull out the hand sanitizer this time could be the slip that reveals you to be an irresponsible or unhygienic person. Nowhere is this identity over-protection clearer than in the case of moral scrupulosity.
In this blog series, I’ll be exploring the form of OCD that manifests most specifically as excessive concern about right and wrong and the false dichotomy of the good person/bad person in OCD. This first entry in the series will focus on defining and recognizing moral scrupulosity in OCD. It’s important to understand that what I am calling “Moral Scrupulosity OCD” here is not a different kind of disorder, just a name to describe a manifestation of OCD for the sake of simplicity. The term “scrupulosity” is often used to describe religious obsessions, which typically manifest as getting too caught up in the details of one’s religious tenets and whether or not they are being perfectly followed. Moral scrupulosity is, thus, obsessive concern with whether or not one is being good or bad, independently from religious expectations. In other words, the concern is with the “quality” of one’s humanity in the context of the culture in which he or she lives. The values and ethics of that culture are the rules that OCD dictates must be followed perfectly. More to the point, this perfection must be constantly proven beyond the shadow of all doubt. Even as I write this, I can sense the itch of my own morality nuisance demanding that I truly capture the suffering of those with moral scrupulosity OCD. I won’t.
Common manifestations of Moral Scrupulosity OCD
Here are some common manifestations of moral scrupulosity I have seen in clinical practice:
Excessive concern with being 100% honest
Excessive concern with the idea of being “good” or of not being “bad” (a so-called “good” person wouldn’t think or do xyz)
Excessive concern with getting in trouble or breaking rules
Excessive concern that a past act was immoral
may include awareness of an actual moral misstep but with obsessive need to know exactly how much
may include concern that others would reject you if they knew about it
may include concern that a thought about an immoral act could be a memory of an immoral act that likely did not even occur (see my blog on False Memory OCD)
Excessive concern that adultery or some disloyal act could have or did possibly take place
Excessive concern that one has caused someone else to be immoral
Moral scrupulosity likes to borrow from other common OCD manifestations. Though the YBOCS has it listed under the subcategory of religious obsessions, moral scrupulosity actually creeps in to nearly every kind of OCD. Here are some examples:
Contamination
It would be morally wrong to touch this with dirty hands
Checking
It would be morally wrong to risk the door being unlocked, the stove being on, etc.
Harm
It would be morally wrong to be careless in a way that could lead to harm
Sexual orientation obsessions
It would be morally wrong to deceive others about my attractions and let them continue to believe I am of one orientation when I could be another
Pedophilia-related obsessions
It would be morally long to have any intrusive thought about a child
Relationship obsessions
It would be morally wrong to let my partner stay in a relationship with someone who has my thoughts
Religious scrupulosity
It would be morally wrong to be philosophically flexible or choose my own interpretation of religious doctrine on moral issues
Compulsions in Moral Scrupulosity OCD
Compulsions, that is, behaviors that OCD sufferers engage in to feel more certain that their fears are untrue, can also cover a wide spectrum of human behavior in moral scrupulosity. Consider that for each individual, what makes them believe themselves to be moral is mediated by their own personal worldview. Often I find that people are engaging in compulsions that look like they serve one function, but really serve another, and this problem of failing to recognize why a compulsion is being done can get in the way of treat the OCD. For example, it’s easy to assume that a person who excessively washes their hands is afraid of being sick. But they may be more concerned with getting others sick. Or, getting themselves or others sick may not even enter into it. They could be simply measuring their moral integrity against the certainty that they are being hygienic. In this case, exposure to the fear of getting or causing illness will be less effective than exposure to the fear of possibly being socially deviant or inadequate.
Here are some common compulsions related to moral scrupulosity:
Common compulsions
Reassurance seeking about moral issues
Confessing perceived immoral acts or thoughts
Mentally reviewing/checking for acts to determine moral integrity
Mental rituals
repeating neutralizing “good” thoughts
ruminating on hypothetical moral scenarios to test responses
repeatedly rationalizing why a past act was not immoral in context
Avoidance of morally ambiguous situations
Self-punishment to prove moral concern
Excessive apologizing for perceived/potential moral failures
Washing and checking behaviors connected to moral concerns
Excessive donating or other acts of exaggerated altruism/generosity
At the core of any obsession is the misguided demand for certainty. Certainty seeking in some areas may, at least, appear more fruitful than in others. For example, you could compulsively check to make sure you’ve turned off the stove. You will see that it is off and that will produce in you a sense that it has been turned off. It’s unlikely to last, of course, but that’s the subject for another blog. But how do you check your morality to make sure it is on or off? You could assign a list of moral guidelines to follow that are consistent with your cultural context, and you can even convince yourself that confidence in this list (as opposed to some other list) is warranted. But at some point you are still going to have to decide whether or not you trust your own judgment, your own memory, and your own self-talk. Though everyone is entitled to a reality check now and then (as in, “come on, it’s not that big a deal), repeatedly reassuring oneself to get certainty always ends up colliding with the wall of reality, that something may be getting missed.
ERP and Moral Scrupulosity OCD
Exposure and response prevention (ERP) is the most effective way to treat any kind of OCD. But you may be concerned that exposure to moral concerns means doing immoral things or may have consequences that are not immediately revealed. In other words, if you have a fear of lying, you may think the best way to do exposure is to lie, but this is not necessarily the case. The exposure to the fear of lying is to engage in behaviors where it is unclear whether a lie has taken place (or the significance of the bent truth is unknown).
Or you may have a fear that you have behaved in an immoral way and that there may be negative consequences that won’t be known for years or decades (e.g. your or someone else’s life is ruined later). This confusion is why it is so important to remember that the battle with OCD is a battle of uncertainty tolerance. The fear to confront over long term damage is the fear that you cannot tolerate sitting with the uncertainty now and for the unknown future.
The Goals of ERP
The goal of ERP is never to prove that you’re a good person. That’s a trap. Any goal that by definition is impossible is obviously no goal worth pursuing. Here are the actual goals of treating your moral scrupulosity with ERP:
Improve uncertainty tolerance
Violate the expectation that uncertainty about morality is intolerable
Improve ability to commit to value-based behaviors despite unwanted thoughts/feelings
Will my therapist make me do terrible things?
ERP therapists make a lot of jokes about doing terrible things, but the truth is we are as invested in preserving your morality as you are. We just don’t believe in certainty. We always work within the client’s moral framework and without the intention to violate it. This requires a fair amount of collaboration so that both the therapist and the client have enough trust between them to take the risk of getting mastery over OCD. First, we need to identify what lines will not be crossed. This is as true in moral scrupulosity as it may be obvious to those with religious scrupulosity. We wouldn’t ask a religious person to knowingly sin and we wouldn’t ask a morally scrupulous person to take money out of a homeless person’s cup – not because we’re especially good people, but because it just doesn’t work. Head on confrontation with uncertainty is what works. So once we’ve identified the lines not to be crossed, we want to explore the area near the line and learn to walk around it more casually, without compulsions, and take ownership of the fact that a gust of wind may accidentally push us over it.
In addition to doing exposures to real life experiences, which often boil down to behaving in ways that are consistent with those around you but without checking and reassurance-seeking about whether you have done so in the most moral way, imaginal exposures can be very useful. Writing scripts articulating that uncertainty will be accepted about morality, that immoral acts could bring about unwanted consequences, or that the scripts themselves are immoral acts can all be effective.
Well, that’s good enough for now…
For now, consider this – OCD is driven by compulsions, behaviors you engage in to make yourself feel certain that you, in this case, are moral. To get you to do compulsions OCD has to cut you down. It has to inundate you with mental spam mail about your perceived moral failings. Learning to live joyfully with uncertainty, even about your inherent “goodness” as a human being is the best strategy for beating OCD and feeling good about yourself. OCD uses the fraudulent concept of “bad person” to con you into trying to prove you are otherwise. I was once asked why OCD never tries to convince you that you are a good person. The answer is that this does not need convincing.
In the next installments of this series I will take a look at some case examples of moral scrupulosity in OCD and how cognitive approaches, self-compassion, and the role of mindfulness can be used in treatment. All of these can be used to enhance your ERP work and liberate you from the irrational fear of being unlovable.
Jon Hershfield, MFT is a psychotherapist in private practice and director of The OCD and Anxiety Center of Greater Baltimore. Follow him on Twitter and Facebook.
May 20, 2018
Me 2.0: Navigating Hyperawareness Obsessions
Your whole life you were one way and now you appear to be another. This statement represents one of OCD’s cruelest, and frankly, laziest efforts to dominate your attention. Once it gets you to sign the contract, that you will commit to being unhappy so long as you are this way now and not the other way as before, you remain its slave. Hyperawareness or sensorimotor obsessions are characterized by an excessive concern that your attention to some otherwise forgettable or involuntary bodily process will become totally and permanently conscious. In other words, we do a lot without thinking about it, so thinking about it feels uncomfortable. Here are some examples of common experiences people with hyperawareness obsessions struggle with:
Blinking
Swallowing
Breathing
Heartbeat
Hunger levels
Bladder or bowel pressure
Itches or minor pains
Hair touching forehead, ears or neck
Positioning of body parts (i.e. where the arms are in relation to the rest of the body, where the tongue rests in the mouth)
Items in the field of vision (e.g. the nose, eye floaters)
White noise (e.g. the hum of a refrigerator)
The very presence of thinking taking place
Like any obsession, there is a fair amount of cross-over into other obsessions. Hyperawareness of the position of or sensations in the groin, for example, are a common issue for those with obsessive fears related to sexual issues. Hyperawareness of sensations in the hands, as another example, can be triggers for obsessive fears of harming self or others. The focus of this blog is primarily on the obsessive concern with the awareness itself.
What Are You Actually Afraid of?
In some cases it may appear that you are simply over-sensitive or have a low tolerance for specific discomforts, but in this form of OCD the problem is that the mind has become overly attached to a specific target and simply stuck there. Efforts to detach the mind from its target seem to have the opposite effect. Why this? You may wonder. In most cases, OCD gets you stuck on unwanted thoughts that are inherently disturbing (e.g. about illness or unwanted sexual or violent thoughts). People who suffer with those types of obsessions don’t want to be stuck there either, but with a sense of purpose. Who would anyone want to think such terrible things? What makes hyperawareness obsessions all the more frustrating is that the person experiencing the obsession is not only stuck, but feels stuck as if with no sense of purpose. Why am I thinking about my breathing instead of just breathing without thinking about it? However, it is not really the case that hyperawareness obsessions have no underlying fears. The seemingly innocuous obsession with unwanted awareness is just the surface of often much darker concerns. Some related obsessive thoughts include:
I will be permanently distracted by these thoughts
I will never feel what it felt like to experience this automatically, without conscious attention
I will be depressed forever because this thought will dominate my attention during meaningful experiences (e.g. my wedding and memories thereof will be ruined by my focusing on my blinking)
I will embarrass myself socially because I can’t pay attention to anything but these thoughts
I will have a mental breakdown, a panic attack, or become psychotic because of constantly thinking about this
More Compulsions Than You’d Think
People with these types of obsessions often assume that they are not doing compulsions because the experience is mostly one of lamenting the intrusive thoughts. I wish I wasn’t thinking about this! But actually many compulsions drive these types of obsessions and being able to identify and esist or interfere with them is key to overcoming this issue. Here are a few examples:
Mental checking to see if awareness is still present
Mental or physical checking to see if the sensation feels “normal”
Repeating the activities (e.g. blinking, swallowing, checking, etc.) a specific number of times or in a ritualistic way to give oneself permission to stop thinking about it
Relying heavily on distraction to avoid having the thoughts
Reassurance seeking that the awareness will go away or that it’s normal to be aware
Mentally reviewing how it must have felt before hyperawareness set in
Avoidance of environments or circumstances where awareness might become more pronounced
Mental rituals (e.g. chants, affirmations, neutralizing statements, etc.) to neutralize the fear of being permanently aware
Cognitive Therapy and Hyperawareness
At the core of these types of obsessions is the problem of over-protecting the present moment. It is what it is, but you’re concerned about ruining it. The idea is that if I am thinking about an involuntary or inconsequential process, then by definition I probably should be thinking about something else. Thinking about the last time I blinked or the next time that I will is the same as squandering attention that could have been placed somewhere more fulfilling or useful (anywhere). Cognitive therapy asks that you take these thoughts and challenge their assumptions. For example “I should not be aware of this” can be challenged as “I don’t to control what’s on my mind and I don’t need more rules”.
Though “should” thoughts take center stage with hyperawarenesss, other common cognitive distortions can be recognized as well. Catastrophizing, for example, can come in the form of “If I don’t stop thinking about this my life will be destroyed”. Magnifying (relating to the thoughts or feelings like they’re a bigger concern than they are) also plays a serious role. Here, a thought like “Oh, no, I’m thinking about my breathing” can be challenged as “Right, so I think about my breathing. Breathing happens.”
Efforts to bring the way you perceive the problem back to an objective viewpoint can help reduce the intensity with which you may feel you have to get rid of the problem. The problem is, after all, not the problem it appears to be. OCD will tell you that the problem is you can’t stop thinking about your awareness. But the actual problem is that you are trying to control your mind. Loosening this control effort opens you up to accept uncertainty and expose to your fear that the uncontrolled mind will contaminate your life.
Exposure and Response Prevention and Hyperawareness
Like exposure and response prevention (ERP) for other forms of OCD, much of it comes down to doing willingly what your mind is doing against your wishes (exposure) and then resisting the urge to flee from the resulting discomfort (response prevention). Compulsive efforts to stop thinking about the obsession only seem to teach the brain that there is something special or interesting about the subject. Instead ERP aims to change the relationship between you and the fact that this thinking is occurring in this way. ERP for hyperawareness obsessions may typically come in the following four forms:
setting up reminders to bring your attention to the target of your obsession on purpose
Like a lot of ERP, this may seem counterintuitive or redundant. After all, you’re already spending a lot of time frustratingly noticing the things you don’t want to notice. However, your experience is almost exclusively on the defensive. The thoughts are intruding and you are trying to keep your cool, trying to make it stop, trying to distract. Lots of trying. By purposely bringing the thought to mind, you take an assertive stance and that means you are approaching ERP from the angle of practicing the work, not trying to avoid it. If the fear is obsessing forever, then trying to obsess denies the OCD its power position. Learning to let go of resistance to the idea that you may obsess forever is the best way to get to the other side and discover that this experience, like all others, is also impermanent.
writing scripts describing the consequences of being permanently aware
Imaginal exposures can be very effective in treating OCD, particularly if the feared outcome is undiscoverable until death. You won’t know if your life has been totally annihilated by your obsession until your life is, well, over. So taking the mind on a fictional journey through a life consumed by your obsession can effectively generate the sense of uncertainty and the emotional terror that comes with it. In a script like this, you could describe what you think it would really be like if this state of hyperawareness was a permanent upgrade to your operating system. The purpose of this exercise is to generate the urge to do compulsions so you can learn to be in the presence of this urge and not give in to it. Through this practice, you also learn to accept uncertainty because you do not automatically get thrown by your uncomfortable feelings.
agreeing with thoughts about permanent awareness
Taking the software upgrade metaphor further, agreeing with your unwanted thoughts about awareness in the moment is also an excellent strategy for breaking down the resistance that keeps the obsession alive. The OCD may say “You’re thinking about swallowing again and it’s going to take over your life!” You say, “You bet. The old version of me was relatively unaware of when or why I swallowed and how it felt, but Me 2.0 is always aware.” This approach takes the ind out of OCD’s sails and leaves it with little else to threaten you.
Putting yourself in likely triggering situations
Instead of trying to get to a distracted place where you feel free of your hyperawareness triggers, you can expose yourself to environments where triggers are likely to come up. One way to do this may be to consider what things you have already been avoiding. For example, engaging in social behavior can be an exposure if you have hyperawareness obsessions about eye contact. Meditating, especially in a style that focuses on the breath, can be excellent ERP for obsessions about breathing.
Mindfulness and Hyperawareness
The whole purpose of mindfulness is to increase your awareness of what the mind is doing in the present moment, so it may seem counterintuitive to use mindfulness as a part of treatment for hyperawareness OCD. But this concern reveals the actual problem with hyperawareness obsessions. You are aware that the mind is attending to something, so in a sense you are being mindful there, but you are missing the opportunity to also be mindful of the resistance to that attention. Instead of noticing the resistance as simply another object of attention, you are identifying with the resistance, which is feeding the OCD. In other words, the wish that you not think about [insert target here] is also something to be mindful of. In meditation practice, you can learn to identify resistance as an object of attention and notice when you are trying not to think something when it would be more skillful to simply observe that thinking is present. When you let go of the drive to stop thinking about your awareness, you may feel discomfort, a sense that the walls are closing in or your time is running out somehow. This discomfort is a feeling and, thus, subject to the same rules as any other object of attention.
People with hyperawareness or sensorimotor obsessions may feel isolated from the rest of the OCD community. It is easy to make the mistake of thinking that it isn’t OCD because the compulsions are not so visible or the subject matter is not so content-focused. But once you understand how the mind has gotten stuck, you can learn to stop doing what makes sense instinctively (the mental equivalent of flailing about in quicksand) and do the mindfulness and CBT work that can help you get grounded again.
Jon Hershfield, MFT is a psychotherapist in private practice licensed in Maryland, Virginia, and California, and director of The OCD and Anxiety Center of Greater Baltimore. Follow him on Twitter and Facebook.
