Info

Your Anxiety Toolkit - It's a Beautiful Day to Do Hard Things

With over a million downloads, Your Anxiety Toolkit Podcast delivers compassionate, science-based tools for anyone with Anxiety, Panic, OCD, and other mental health struggles.
RSS Feed
Your Anxiety Toolkit - It's a Beautiful Day to Do Hard Things
2022
September
August
July
June
May
April
March
February
January


2021
December
November
October
September
August
June
May
April
March
February
January


2020
December
November
October
September
July
June
May
April
March
February
January


2019
November
October
September
August
July
June
May
April
March
February
January


2018
December
November
October
September
August
July
June
May
April
March
February
January


2017
December
November
October
September
August
July
May
April
March
January


2016
October
September
July
June
May
April
March


All Episodes
Archives
Now displaying: May, 2022
May 27, 2022

SUMMARY:

In this week's podcast, we talk with Dr. Reid Wilson.  Reid discussed how to get the theme out of the way and play the moment-by moment game.  Reid shares his specific strategies for managing mental compulsion. You are not going to want to miss one minute of this episode.

Covered in This Episode:

  • Getting your Theme out of the way
  • The importance of shifting your additude
  • Balancing “being aggressive” and implementing mindfulness and acceptance
  • How to play the “moment by moment” game
  • Using strategy to achieve success in recovery
  • OCD and the 6-moment Game
  • Other tactics for Mental compulsions

Links To Things I Talk About:

Reid’s Website anxieties.com
https://www.youtube.com/user/ReidWilsonPhD?app=desktop
DOWNLOAD REID’s WORKBOOK HERE 

Episode Sponsor:

This episode of Your Anxiety Toolkit is brought to you by CBTschool.com.  CBTschool.com is a psychoeducation platform that provides courses and other online resources for people with anxiety, OCD, and Body-Focused Repetitive Behaviors.  Go to cbtschool.com to learn more.

Spread the love! Everyone needs tools for anxiety...

If you like Your Anxiety Toolkit Podcast, visit YOUR ANXIETY TOOLKIT PODCAST to subscribe free and you'll never miss an episode. And if you really like Your Anxiety Toolkit, I'd appreciate you telling a friend (maybe even two).

Managing Mental Compulsions (With Dr. Reid Wilson) Your anxiety toolkit

EPISODE TRANSCRIPTION

This is Your Anxiety Toolkit - Episode 286.

Welcome back, everybody. I am so excited. You guys, we are on number five of this six-part series, and this six-part series on Managing Mental Compulsions literally has been one of the highlights of my career. I am not just saying that. I’m just flooded with honor and pride and appreciation and excitement for you. All the feedback has been incredible. So many of you have emailed me or reached out to me on social media just to let me know that this is helping you. And to be honest with you, I can’t thank you enough because this has been something I’ve wanted to do for so long and I’ve really felt that it’s so needed. And it’s just been so wonderful to get that feedback from you. So, thank you so much.

The other plus people I want to be so grateful for are the guests. Each person has brought their special magic to how to manage mental compulsions. And you guys, the thing to remember here is managing mental compulsions is hard work, like the hardest of hard work. And I want to just honor that it is so hard and it is so confusing and it’s such a difficult thing to navigate. And so, to have Jon talking about mental compulsions and mindfulness and Shala talking about her lived experience and flooding, and Dr. Jonathan Grayson talking about acceptance last week. And now, we have the amazing Reid Wilson coming on and sharing his amazing strategies and tools that he uses with his patients with mental rumination, mental compulsions, mental rituals. Literally, I can’t even explain it. It’s just joy. It’s just pure joy that I get to do this with you and be on this journey with you.

I’m going to do this quick. So, I’ll just do a quick introduction. We do have Dr. Reid Wilson here. Now we’ve had Reid on before. Every single guest here, I just consider such a dear friend. You’re going to love this episode. He brings the mic drops. I’m not going to lie. And so, I do hope that you squeeze every little bit of juice out of this episode. Bring your notepad, get your pen, you’re going to need it, and enjoy. Again, have a beautiful day. As I always say, it is a beautiful day to do hard things. Let’s get onto the show.

Kimberley: I am thrilled to have you, Dr. Reid Wilson.

Reid: Thanks. Glad to be here.

Kimberley: Oh my goodness. Okay. I have been so excited to ask you these questions. I am just jumping out of my skin. I’m so really quite interested to hear your approach to mental compulsions. Before we get started, do you call them mental compulsions, mental rituals, mental rumination? How do you--

Reid: Sure. All of the above doesn’t matter to me. I just don’t call it “pure obsessions, pure obsessionals” because I think that’s a misnomer, but we can’t seem to get away from that.

Kimberley: Can you maybe quickly share why you don’t think we can get away from that? Do you want to maybe-- we’d love to hear your thoughts on that. We haven’t addressed that yet in the podcast.

Reid: Well, typically, we would call-- people write to me all the time and probably do that too, say, “I’m a pure obsessional.” Well, that’s ridiculous. Nobody’s a pure obsessional. What it really is, is I have obsessions and then I have mental compulsions. And so, it’s such a misnomer to be using that term. But what I mean is, how we can’t get away from it is it’s just gotten so completely in the lexicon that it would take a lot of effort to try to expel the term.

Getting the theme out of the way

Kimberley: Okay. Thank you for clearing that up, because that’s like not something we’ve actually addressed up until this time. So, I’m so grateful you brought that up. So, I have read a bunch of your staff. I’ve had you on the show already and you’re a very dear friend. I really want to get to all of the main points of your particular work. So, let’s talk first about when we’re managing mental compulsions. We’ll always be talking about that as the main goal, but tell me a little bit about why the theme, we’ve got to get out of the way of that.

Reid: Right. And my opinion is this is one of the most important things for us to do and the most difficult thing to accomplish. It’s really the first thing that needs to be accomplished, which is we have to understand. And you’re going to hear me say this again. This is a mental health disorder and it’s a significant disorder. And if we don’t get our minds straight about what’s required to handle it, we’re going to get beaten down left and right. So, of course, the disorder comes into the mind as something very specific. Focusing on the specific keeps us in the territory of the disorders control. So, we need to understand this is a disorder of uncertainty. This is a disorder of uncertainty that brings distress. So, we have that combination of two things. If we’re going to treat the disorder, we cannot bring our focus on our theme. But the theme is very ingrained in everyone. 

I talk about signal versus noise, and this is how I want to help people make that transition, which is of course, for all of us in all humanity, every worry comes into the prefrontal cortex as a signal. And we very quickly go, “Oh yeah, well, that’s not important. I don’t need to pay attention to that.” And we turn it over to noise and let go of it and keep going. With OCD, the theme, the topic, the checking, and all the mental rituals that we do are perceived and locked down as signals. And if we don’t convert them into noise, we are stuck. 

What I want the client to do is to treat the theme as nothing, and that is a big ask. And not only do we have to treat the theme as nothing, we have to treat it as nothing while we are uncertain, whether it’s nothing or not. So, in advance of an obsession popping up, we really need to dig down during a no problem time and get clear about this. And then we do want to figure out a way to lock that down, which includes “I’m going to act as though this is nothing,” and it has to be accomplished like that. Go ahead.

Kimberley: No. And would you do the same for people, let’s say if they had social anxiety or health anxiety, generalized anxiety? Would you also take the theme out of it?

Reid: Absolutely. But if the theme is in the way, then we need to problem-solve that. So, if we go to health anxiety, okay, I’ve got a new symptom, some pain in the back of my head that I’ve never had before. I have to decide, am I going to go into the physician and have it checked out or am I not? Or am I going to wait a few days and then do it? With that kind of anxiety and fear around health, we have to get closure around “I don’t need to do anything about this.” Sometimes I use something called “postponing.” So, with social anxiety, it can-- I mean, with health anxiety, it can work really well to go, “Well, I’m having this new symptom, do I have to immediately go in and see the physician and get it checked out? Can I wait 24 hours? Yes, I can. I’ve already been diagnosed with health anxiety. So, I know I get confused about this stuff. So, I’m going to wait 24 hours.” So, what does that give us then? Now I have 24 hours to treat the obsession as nothing because I don’t need to focus on it. I’ve already decided, if I’m still worried tomorrow, I’m making an appointment, we’re going in. That gives me the opportunity to work on this worry as an obsession because I’ve already figured it out. The reason we want to do that so diligently is we have to go up one level of abstraction up to the disorder itself. And that’s why we have to get off of this to come up here and work on this.

Kimberley: This is so good. And you would postpone, use that same skill for all the themes as well? I’m just wanting to make sure so people clarify.

Reid: Well, sure. I mean, postponing is a tactic. I wouldn’t say we can do postponing across the board because some people have-- it really depends on what the obsession is and what the thinking ritual is as to whether we can use it. But it’s one of them that can be used.

Shifting your attitude 

Kimberley: Amazing. Tell me about-- I mean, that requires a massive shift in attitude. Can you share a little bit about that?

Reid: Yeah. And if you think about-- I use that term a lot around attitude, but we’ve got some synonyms in attitude. What is my disposition toward this? Have I mentioned mental health disorder? What do I want my orientation to be? How do I want to focus on it? And we want to think about really attitude as technique, as skill set. So, what we know is the disorder wants some very specific things from us. It wants us to be frightened by that topic. It wants us to have that urge to get rid of it and have that urge to get rid of it right now. And so, that begins to give us a sense of what is required to get better. And that again is up here. 

So, why do you do mental counting? Why do you do rehearsal mentally? Why do you try to neutralize through praying? When you look at some of those, the functions of some of those or compulsions and urge to do the compulsions, it is to fill my mind so I don’t get distracted again, it is to reassure myself, it is to make sure everything is going to be okay. It is to get certain. And so, when we know that that is the drive of the disorder, we begin to see, what do we need to do broadly in general? And that is, I need to actually operate paradoxically. If it needs me to do this, feel this, think this, I’m going to do everything I can to manipulate that pattern and do the opposite. It wants me to take this theme seriously, I’m going to work on-- and really it has to be said like that. I’m going to work on not taking it seriously. So, that’s the shift. If we can get a sense of the attitude and the principles that go along with all of that, then moment by moment, we’ll know what to do in those moments.

Do you need to be aggressive with OCD and intrusive thoughts? 

Kimberley: We’ve had guests talking about mindfulness and we will have Lisa Coyne talking about act and Jon Grayson talking about acceptance, and you really talk more about being aggressive. How do you feel about all of those and where do they come together, or where are they separate? How would you apply these different tools for someone with mental compulsions?

Reid: Yeah, sure. Mindfulness is absolutely a skill set that we need to have. Absolutely. We are trying to get perspective. We’re trying to get some distance. We would like to detach. That’s what we’re trying to do. But what are we trying to be mindful of? We’re trying to be mindful of the belief that this topic is important. We’re trying to be mindful of the need to ritualize that is created by the theme. So, the end game is mindfulness and detachment. That’s where we’re going. My opinion is, the opening gambits, the opening moves, it’s very difficult to go from a frightened, terrified, scared, and slide over to neutral and detached. It’s just difficult. 

And so, I think initially, we need to be thinking about a more aggressive approach, which is I’m going to go swing in this pendulum from, “I can’t stand this, this is awful.” I’m going to swing over right past mindfulness over to this more aggressive stance of, “I want this, let’s get going. I’m taking this theme on.” The aggressiveness is a determination of my commitment to do the work. 

And here’s the paradox of it. I’m going to address on the disorder by sitting back. My action is to go, “I’m okay. This is all right.” And that’s a mindful place to get to. But you have to know we’re going after this big, aggressive bully, and it requires an intense amount of determination and you have to access your determination over and over and over again. You don’t just get determined and it’s steady. So, we just got to keep getting back to that. “No, no, I want to do this work. I want to get my outcome picture. I want to have my mind back. I want to go back to school. I want to be able to connect with my family in a loving way, with having one-third of my mind distracted. I want that back very strongly. And therefore, If I have to go through this work to get there, I want to go through this work.” We can maybe talk more about what that whole message of “I want this” means, but here it is, which is, “I want this” is a kind of determination that’s going to help drive the work.

Kimberley: Yeah. Let’s go there because that is so important. So, tell me about “I want this.” Tell me about why that is so important. So, you’ve talked about “I want to get better and I want to overcome this,” and so forth. Tell me more about the “I want this comfort.”

Reid: Well, let’s think about-- you really only have two choices in terms of your reaction to any present moment, either I want this moment, so I’m present to this moment, or I don’t want this moment. It’s very simple in that way. When I don’t want this moment, I’m now resisting this present moment. And what that means practically speaking is, now I’ve taken part of my consciousness, part of my mind that is available for the treatment and I’ve parked it. I’ve taken it offline and actually provoking myself, sticking myself with, “Are you sure you want to do this? Is this really safe? Don’t you think-- maybe we could do this later and not now.” So, there’s a big drive to resist that we need to be aware of. Have I mentioned this yet? This is a mental health disorder that is very tough to treat. I want 100% of my mental capacities available to do the treatment. I’ll never have all of that because I’m always going to have some form of resistance, but I need to get that resistant part of me on the sideline not messing with me, and then let me go forward all like that. 

One of the confusions sometimes people get around this work when I talk about it is it’s not, “Oh, I want to have another obsession right now,” or “I want to have an urge to do my compulsion right now. I want that.” No. What we’re talking about is a present moment. So, if my obsession pops up, if it pops up, I want it. If I’m having that urge to do my compulsion, I want it. And why is that? Because we have to go through it to get to the other side. I have to be present to both the obsessions and the urges to do the compulsions in order to do the treatment. So, that’s the aggressive piece. “Come on, bring it on. Let’s get going. I’m scared of this.” Of course, I don’t want--

Kimberley: I’m just going to ask.

Reid: I don’t want to feel it. I don’t want to, but I’m clear that to do the treatment, it requires me to go through the eye of the needle. If you’re like I am, there’s plenty of days when you don’t want to go to the gym. You don’t really want to work out or sometimes you don’t even want to go to bed as early as you should, but if we want the outcome of that good rest, that workout, then we manifest that in the moment and get moving.

We’re disrupting a pattern. When I talked about postponing, it’s a disruption of this major pattern. If we insert postponing into these obsessions and mental compulsions are impulsive, I have that obsession and I pretty immediately have that urge to do the compulsion. And then I begin doing my mental compulsion. If we slide something in there, that’s what mindfulness does go, “Oh, there it is again. Oh, I’m doing it.” Even if you can’t sustain that, you’ve just modified for a few moments, the pattern that you’ve had no control over. So, that’s where we want to be going. And you know how I sometimes say it is, my job is to-- as the client is to purposely choose voluntarily to go toward what scares the bejesus out of me. I don’t know if you have bejesus over there in California, but in North Carolina, we got bejesus, and you got to go after it.

Kimberley: I think in California, it’s more of a non-kind word.

Reid: Ah, yes. Okay. Well, we won’t even spell it.

The Moment By Moment Game 

Kimberley: That’s okay. So, I have questions. I have so many. When you’re talking about this moment, are you talking about your way of saying the moment-by-moment game? Is that what you’re talking about? Tell me about the moment-to-moment game.

Reid: Sure. I’m sure people hearing this the first time would go, “Well, don’t be-- you’ve lost rapport with me now because you called it a game.” But I’ve been doing this for 35 years, so it’s not like I am not aware of the suffering that goes on here. The only reason to call it a game is simply to help structure our treatment approach.

Kimberley: That’s interesting, because I think of a game as like you’re out to win. There’s a score. That’s what I think of when I--

Reid: That’s what this is. That is actually what this is. 

OCD and the 6 Moment Game 

Kimberley: I don’t think of it as a game like Ring A Rosie kind of stuff. I think of it as like let’s pull our socks up kind of stuff. Is that what you’re referring to?

Reid: We’ve got this mental game that we are-- we’ve been playing this game and always losing. So, we’re already engaged in it. We’re just one down and on the losing end, on the victim end. So, when I talk about it as moment by moment, I want to have, like we’ve been talking about, this understanding of these sets of principles about what needs to happen. It wants me to do this, I’m going to do the opposite, this is paradoxical and so forth. And then we need to manifest it moment by moment. So, how do we do this? I will really talk about six moments and I’ll quickly go through the first three because the first three moments are none of our business. We can’t do anything about them. 

So, moment #1 is just an unconscious stimulus of the obsession, and that’s all. That’s all it is. Moment #2 is that obsession popping up. And moment #3 is my fear reaction to the obsession because obsessions are frightening by their construct. And so, now I’ve got those three moments. As I’m saying, we can’t do anything about those three moments. These three moments are unconsciously mediated. They are built right on into the neurology. 

Now we’ve got in my view three more moments. So, moment #4 is really the foundation of what we do now, what we do next, which is a mindful response. And it is just stepping back in the moment. Suddenly the obsession comes up and I’m anxious and I’m worried about it and I’m having the urge to do the compulsion. And what I want to train myself to do, which can take a little time sometimes, is when I hear my obsession pop up. The way I just described it right there is already a stepping back. When I recognize that I’ve started to obsess and sometimes it takes a while to even recognize it, I want to step back in that moment and just name it. They have that expression, “Name it to tame it.” So, it’s the start of that. So, I’m stepping back in that moment going, “Oh, I’m doing it again,” or, “Oh, there it is.”

Now, the way I think about it, if I can do that and just step back and name it, I just won that moment because I just inserted myself. I insinuated myself into the pattern. OCD doesn’t want you anywhere near this at this moment. It doesn’t want you to be labeling the obsession an obsession. It wants you to be naming the fearful topic of it. So, I’m going to step back in that moment. And if I can accomplish that, great, I’ve won that moment. 

If I can go further in that moment, of course, in the end, we want to be able to do that, moment #5 is taking the position of, “I’m treating this as nothing. There is my obsession. I’m treating it as nothing.” And there’s all kinds of things you can say to yourself that represent that. “This is none of my business. Oh, there it is trying to go after me. Not playing. I’m not playing this game.” Because it really is a game that the disorder has created. And what we’re saying is, “Look, I’m not playing your game anymore. I’m playing my game. And this is what my game looks like.” I’m going to notice it when it pops up, the obsession and the urge to do my compulsion, and I’m going to go, “Not playing,” whatever way I say it. 

And then moment #6, and this is a controversial moment for others. Moment #6, I’m going to turn away from it. I’m going to just redirect my attention, because this is nothing, but it’s drawing my attention. I’m going to treat it as nothing by engaging in some other thought or action that I can find. And even if I can refocus my attention for eight seconds, even if it pops right back up again like, “Where are you going? This is important. You need to pay attention to it,” even if I turn away for eight seconds, I’ve won that moment because I’m no longer responding to this over here. 

Now, why I say this is controversial for some folks is it sounds like distraction. It sounds like, “Oh, you’re not doing exposure. You’re just telling the person to distract themselves. And that’s opposite of what we want to be doing.” I don’t see it that way. 

Kimberley: No, I don’t either. I think it’s healthy to engage in life. 

Reid: And if we think about, what we’re really trying to do is to sit with a generic sense of uncertainty, then this allows us to do it because, in essence, the obsession is a kind of question that is urging you to answer. And when you turn away, engage in something else, you are leaving that question on the table. And that is exposure to pure uncertainty. I just feel like in our field, in exposure, we’re doing so much to ask people to expose themselves to the specifics and drill down about that as a way to change neurology. And we know that’s really the gold standard based on all the research that has been done. But I think it really adds a degree of distress focusing on that specific that maybe we can circumvent. 

Kimberley: Do you see a place for the exposure in some settings? I mean, you’re talking about being aggressive with it. Does that ever involve, like you said, staring your fear in the face purposely?

Reid: Well, yeah. And how do you do that? Well, what you do is you either structure or spontaneously step into circumstances that would tend to provoke the obsession. So, do something that I’ve been avoiding for fear that thought is going to come up or anything that I have been blocking or avoiding out of fear of having the obsession or anything that tends to provoke the obsession. I want to step into those scenes. So, step into the scene, but the next move isn’t like, “Okay, come on obsessions. I need to have an obsession now.” No. If you step into the scene that typically you have an obsession with and you don’t have the obsession, well, that’s cool. That’s fine. That’s progress. That’s great. Now you got to find something else to step into it with. However, most people with thinking rituals, it goes on most of the day anyway. So, we’re going to have a naturalistic exposure just living the day. 

Kimberley: The day is the exposure.

Reid: And for people who are structuring it and you know you’re about to step into a scene where you have the obsession, you can, in that way, be prepared to remind yourself, cue yourself ahead of time what your intention is. The more difficult practice is moving through your day and then getting caught by it. So, you get caught by it and then you start digging to fix the content and it takes a little more time to go, “Oh, I’m doing it again.” We’re doing exposure. This is exposure. You have to do exposure. I’m just saying that there’s a different way to do it instead of sitting down and conjuring up the obsession in order to sit with the distress of the specific.

Kimberley: I’m going to ask you a question that I haven’t asked the others, just because it’s coming up specifically for me. Some clients or some of my therapist clients have reported, “Okay, we’re doing good. We’re doing good. We’re not doing the mental compulsion.” And the obsession keeps popping up. “Come on, just a little. Come on, let’s just work it out.” And they go, “No, no, no, not engaging in you.” And then it comes back up. “No, no, no, not engaging in you.” And much of the time is spent saying, “Not today, not today,” or whatever terminology. And then they become concerned that instead of doing mental compulsions, they’re just spending the whole time saying, “Not today, not today.” And they’re getting concerned. That’s becoming compulsive as well. So, what would you say? Are you feeling like that’s a great technique? Where would you intervene if not?

Reid: Well, I think it’s fine if it is working like we’re describing it, which is not today, turning away, engaging in something else. So, we’ve got to be careful around this “not today” thing if you forget to do--

Kimberley: The thing

Reid: Moment #6, which is find something else to be engaged in. Then you’re going to be-- it’s almost, again, you’re trying to neutralize, “Oh, this is nothing.” So, we want to make sure that we really complete the whole process around that. And the other way that we-- again, mindfulness and acceptance, the way we can get to it is we have the expression of front burner and back burner. So, we want to take the obsessiveness and the urges and just move them to the back burner, which means they can sit there, they can try to distract you, they can try to pull your attention. So, here you are at work and you’re really trying to do right by the disorder, but you’re trying to work, and it’s still coming over here trying to get to you. You’re going to be a little distracted. You’re not going to be performing your work quite as well as you would if your mind were clear. And that is the risk that you need to take. That is the price that you need to pay. And that’s why you need to have that determination and that perspective to be able to say, “Geez, this is hard. This is what I need to be doing.” You have to talk to yourself. You have to. We talk to ourselves all day long. This is thinking, thinking, thinking. So, we know people with thinking rituals are talking about the urges and so forth. And we’ve got to redirect how we talk about it in the moment.

Kimberley: Okay. So good. What I really want to hear about is your ideas around rules. 

Reid: Sure. And again, nobody seems to talk about rules. I’m a very big component or a proponent of rules. And here’s one reason. What are thinking rituals all about? It’s all about thinking, thinking, thinking, thinking, thinking. What do we need to do in the treatment strategy? Well, first off, the disorder is compelling me to fill my mind with thoughts in order to feel safe. I need to come up with a strategy and tactics that reduce my thinking. Then if I don’t reduce my thinking, I’m not going to get stronger. One of the ways to reduce my thinking is to say, “I don’t need to think about this anymore. I’ve already figured out what I need to do.” So, during no problem times, during therapeutic times, whether you’re sitting with your therapist or figuring this out on your own, you come up with literally what we’ve been talking about, “What I need to do when an obsession takes place? And then here’s what I’m going to do next.”

Kimberley: So, you’re making decision--

Reid: I’m going to turn my attention. I’m sorry, go ahead.

Make Decisions Ahead of Time

Kimberley: Sorry. You’re making decisions ahead of time. Is that what you mean?

Reid: Absolutely. You’re making decisions. This is rules of engagement. So, we’re not talking about having to get really specific moment by moment. We’re talking about thinking rituals. So, it’s rules of engagement. Well, simply put, initially, the rule of engagement has to do with those six moments we talked about, which is, okay, when this pops up, this is how I’m going to respond to it. So, we want to have that. All that we’ve talked about decide that ahead of time. And then as I would say, lock it down, lock it down. And now the part of you who is victim to the disorder, when the obsessiveness starts again, when the urge to do the compulsion starts again, I want to have all of me stand behind the rules, because if we don’t have predetermined rules, what is going to run the day? What’s going to win the day? What’s going to win the day in the moment is the disorder shows up. The victim side, the victim to the disorder is also going to show up and it’s going to say, those rules that I was talking about before, “This seems like a bad idea. I don’t think in this circumstance that’s the right thing to do.” So, if we don’t lock it down and we don’t have a hierarchy, which is, what I was saying, we’re not killing off the side of us that gets obsessive and is being controlled by the disorder. But we are elevating the therapeutic voice, “I’ll do that again with my hands.” 

This is a zero-sum game. So, if I bring my attention to what I’ve declared what I need to do now, then by default, my attention toward that messages of my threatened self are going to diminish. And this is what I’ve been talking about with you around determination. You have to be so determined, because it’s so tantalizing. Even if they say this isn’t going to take me very long to complete this mental ritual, and then it’ll be off my plate, and I won’t have to be scared about the outcome of not doing this, why wouldn’t I do that? So, that’s what we’re really competing against in those moments of engagement.

Thinking Strategically

Kimberley: Right. So good. I’m so grateful for what you’re sharing. Okay. I want to really quickly touch on, and I think you have, but I want to make sure I’m really clear in terms of thinking strategically. It sounds like everything you just said is a part of that thinking strategic model. I love the idea that you come into the day, having made your decisions upfront with the rules. You’ve got a plan, you know the steps in the moment. Thinking strategically, tell me if that’s what that is or if there’s something we’ve got to add to it.

Reid: Yeah. So, yes, all that you just said is that, that we’re understanding the principles of treatment based on the principles of what the disorder has intended for us. And then we’re trying to manifest those principles in, how do we act in the moment? How do we engage in that in the moment? The other thing we want to think about in terms of how I think about strategic treatment is we’re looking for the pattern and messing with the pattern. So, I talked earlier about postponing. We insert postponing into the pattern. It’s much easier to add something to a pattern than to try to pull something away. So, if we add postponing or add that beat where I go, “Oh, there’s my obsession,” now we’re starting to mess with the pattern. I’ll give you a couple of-- these are really tactics. Let me tell you about a couple of others and these seem surprisingly ridiculous. Okay, maybe not surprisingly ridiculous. 

Kimberley: Appropriately ridiculous. 

Reid: I’m sure you experience this. I experience a lot where people go, “Look, I’d love to do what you’re saying, but these obsessions are just pounding away at me all day long. I can’t interrupt them. I can’t do it.” What I would like people to be focused on is, what can we do to make keeping the ritual, keeping the obsession more difficult than letting it go? So, we talked about postponing. That doesn’t quite do what I’m saying right now. One of the things I’ll have people do is to sing it. I know, and I’m not going to demonstrate.

Kimberley: Please. I will. 

Reid: And here’s what you do. If I can’t stop my obsessions, I can’t park them, then when I notice – there’s moment #4 – when I notice my obsessions-- and we can do this in a time-limited-- I’m a cognitive therapist, so we do behavioral experiment. So, we can just do an experiment. We can go, “Okay, for the next three days, three weeks, three hours, whatever we decide, anytime I notice the obsession coming up, instead of saying it urgently and anxiously in my mind, I must sing it.” It just means lilting my voice. “Oh my gosh, how am I ever going to get through this? I don’t count the tiles on the ceiling. I’m not sure I can really handle what’s going to happen next. Oh my gosh, I feel so anxious about--” you see why I don’t demonstrate.

Kimberley: Encore, encore.

Reid: SO, it’s just lilting the voice like that. A couple of things are going on. One is obviously we’re disrupting the pattern. But just as important, who in their right mind, having a thought that is threatening, would sing it? So, simply by singing my obsession instead of stating it, I’m degrading the content, I’m degrading the topic. And so, that’s why I would do it. And again, that’s what we were saying. You got to lock it down. You got to go signal versus noise. This is noise. It’s acceptable to me to be doing this. This is very difficult. With such a short period of time, I don’t drill that home as much as I might. This is really, really hard, but it is an intervention.

So, singing it is one thing that I will sometimes have some people do. And the other one is to write it down. And this means literally carrying a notepad with you and a pen throughout your day. And anytime your obsession starts to pop up, you pull that notepad out and you start writing your obsession. And I’m not saying put it in an organized paragraph fashion or a bulleted list or anything like that. We’re talking about stenographer in the courtroom. I want to, in that moment, when I start obsessing, to step back, pull out my notepad, because I said for the next three days, I’m going to do this, and then I’m going to write every single thing that’s popping up in my mind. 

Kimberley: So, it’d be like, “What if you want to kill her? You might want to kill her. There’s a knife. I noticed a knife. Do I want to kill her with a knife? Am I a bad person?”

Reid: Oh, it’s harder than that. It’s harder than that, Kimberley, because you’re not only saying, “Do I want to kill her? There’s the knife. Oh, what did I just say?” Now I got to write, “Oh, what did I just say? Oh, the knife. Oh, the knife. Do I want to kill her with the knife?” So, every utterance, we’re not saying every utterance. And so, there’s going to be a message of, “Did I just say that right? Now I can’t remember what I said. Damn it, damn it.” All of that. Now, again, a couple of things are happening. I’m changing modes of communication. The disorder wants me to do this by thinking. You and I know, you can have an obsessive thought a thousand times in a day. You can’t write it a thousand times. So, now we’re switching from the mode of communication that serves the disorder to a mode of communication that disrupts it. And if I really commit myself to writing this, after a while, now I’m at a choice point. Now when obsession pops up later and I go, “Oh, I’m obsessing again. Well, I can either start writing it,” or “Maybe I can just let it go right now because I don’t want to write it. It’s just so much work. Okay, let me go distract myself.” So, all of a sudden, we’ve done exposure and response prevention without the struggle, because I don’t want to do what I have agreed to do locked down, which is write this. 

So, it empowers. Writing it, just like singing it, empowers me to release it, especially people with thinking rituals. The whole idea of using postponing around the rituals, singing the obsession if I need to, writing down the obsession as tactics to help break things up, and then just keep coming back to what’s our intention here. This is a mental health disorder. I keep getting sucked into the topic. I don’t think I can-- here’s I guess the last thing I would say on my end is, this is it, which is, I don’t know if this is going to work. I don’t know how painful whatever is coming next is going to be by not doing my ritual. I am going to have faith. I mean, this is what happens. You have to have faith and a belief in something and someone outside of your mind, because your mind is contaminated and controlled by the disorder. You can’t keep going up into your thinking and try to figure out how to get out of this wet paper bag. You’re just not-- you can’t. So, you got to have faith and trust. And that’s a giant leap too. Because initially, when we do treatment with people, however we do it, they’ve got to be doing something they don’t know is going to be helpful. 

When people start doing the singing thing or the writing down thing, for instance, after a while, they go, “Wow, that really worked. Okay, I’m going to do that some more.” And that’s what we need. Initially, you just have to have faith and experiment. That’s why we like to do short experiments. I don’t say, “Hey, do this over the next 12 weeks and you’ll get better.” I go, “Look, I know you think this over here, I’m thinking it’s this over here. How about we structure something for the next X number of minutes, hours, days, and just see what you notice if you can feel like you can afford to do that.” 

Kimberley: So good. I’ve just got one question and then I’m going to let you go. I’m going to first ask my question and then I want you to explain, tell us about your course. When you sing the song, I usually have my staff sing it to a song they know, like Happy Birthday or Auld Lang Syne, whatever it may be. You are saying just up and down, “No, no, no,” that kind of thing. Is there a reason for that?

Reid: Well, I don’t want people to have to make a rhyme. I don’t want them to have to--

Kimberley: It’s just for the sake of it.

Reid: I’m totally fine with what you’re saying. Okay, I’m going to-- you can figure it out. It’s like going, “Okay, anytime I hear my obsession come up, I’m going to make my obsession the voice of Minnie Mouse. So, I’m going to degrade it by having to be a little mouse on my shoulder, anything to degrade it.” If you’ve got to set little songs or you ask your client what they would put it to, then yeah. And then in the session, we’re talking about the therapist, demonstrate it and have them practice it with you in order to get it.

Kimberley: Right. I’ve even had clients who are good at accents, like do it in different accents. They bring out--

Reid: You’ve got a good one. You’re really practicing that Australian accent.

Kimberley: Very. I practiced for many years to get this one. All right. You talk about the six-moment game. I’ve had the joy of having taken that course. Can you tell us if that’s what you want to tell us about, about where people can hear about you and all the good stuff you’ve got?

Reid: Sure. Well, I would start with just saying anxieties.com. It’s anxieties, plural, .com. And that’s my website, a free website. It’s got every anxiety disorder and OCD. You’ve got written instruction around how to do some of the work that we’re talking about. And then I’ve got tons of free video clips that people can watch and learn a bunch of stuff. I laid out, in the last two years, a four-hour course, and I filmed it. And so, it is online now. I take people all the way through what I call OCD & the 6-Moment Game: Strategies and Tactics, because I want to empower people in that way. So, I talk about all the stuff that you and I are rushing over right now. It’s got a full written transcript as an eBook, a PDF eBook. I’ve got a workbook that lets people figure out how to do these practices on their own. All of that. In fact, you can get-- I can’t say how to get it at this moment. Maybe you can post something, I don’t know. But I will give anybody the workbook, that’s 37 pages, and it takes you through a bunch of stuff. No cost to you, send it to anybody else you want. 

So, I feel like that, first off, we don’t have enough mental health professionals to treat the people with mental health disorders in this world today. And so, we need to find delivery systems. That will help reach more people. And I believe in Stepped Care. And Stepped Care is a protocol, both in physical medicine and in mental health, which says that first step of Stepped Care and treatment is self-help. And I call it self-help treatment, because the first step is relatively inexpensive, empowering the patient or the client, and giving them directions about how to get stronger. And a certain percentage of people, that will be enough for them. And so, all of us who have written self-help books and so forth, that’s our intention. And now, I’m trying to go one step beyond self-help books to be able to have video that gives people more in-depth. 

What I want is for that first step, the principles that are in that first step, go up to the next step. So, if a self-help course or a book or whatever is not sufficient to finish the work, then you go up one level to maybe a self-help group or a therapeutic group and work further there. And if you can’t complete your work, then go up the next step, which is individual treatment, the next step, which is intensive outpatient treatment, the next step, mixture medications, and so forth. And so, if we can carry a set of principles up, then everybody’s on the same page and you’re not starting all over again. So, I focus on step one. I’m a simple guy.

Kimberley: I’m focused on step one too, which is what you’re doing with me right now, which makes me so happy. I’m so grateful for you for so many reasons.

Reid: Well, I’m happy to be doing this, spending time with you. It’s great. And trying to figure out how to deliver the information concisely. It’s still a work in progress. Thank you for giving me an opportunity.

Kimberley: No, thank you. I’ve loved hearing about all of these major points of your work. I’m so grateful for you. So, thank you so much for coming on again. I didn’t have a coughing fit during this episode like I did the last one.

Reid: Nothing to make fun of you about.

Kimberley: Thank you so much, Reid. You’re just the best.

Reid: Well, great constructing this whole thing. This is what I’m talking about too, is to have a series of us that eventually everybody will see and work their way down and get all these different positions and opinions from people who already do this work. And so, that’s great. You have a choice, so that’s great.

Kimberley: Love it. Thank you.

Reid: Okay. Talk again sometime.

May 20, 2022

SUMMARY:
In this weeks podcast, we talk with Dr Jon Grayson about managing mental compulsions. Jon talks about how to use Acceptance to manage strong intrusive thoughts and other obsessions. Jon addressed how to use acceptance with OCD, GAD and other Anxiety disorders.

Covered in This Episode:

  • What is a Mental Compulsion?
  • What is the difference between Mental Rumination and Mental Compulsions?
  • How to use Acceptance for Mental Compulsions
  • How to practice acceptance when the intrusive thoughts are so strong.

Links To Things I Talk About:

Jon’s Book Freedom from Obsessive Compulsive Disorder: A Personalized Recovery Program for Living with Uncertainty
Jon’s Website https://www.laocdtreatment.com/
ERP School: https://www.cbtschool.com/erp-school-lp

Episode Sponsor:
This episode of Your Anxiety Toolkit is brought to you by CBTschool.com. CBTschool.com is a psychoeducation platform that provides courses and other online resources for people with anxiety, OCD, and Body-Focused Repetitive Behaviors. Go to cbtschool.com to learn more.

Spread the love! Everyone needs tools for anxiety...
If you like Your Anxiety Toolkit Podcast, visit YOUR ANXIETY TOOLKIT PODCAST to subscribe free and you'll never miss an episode. And if you really like Your Anxiety Toolkit, I'd appreciate you telling a friend (maybe even two).

EPISODE TRANSCRIPTION

This is Your Anxiety Toolkit Episode - 285.

Welcome back, everybody. We are on episode three of the six-part series. And if you have listened to the previous episodes, I am sure you are just full of information, but hopefully ready to hear some more.

Today, we have Dr. Jonathan Grayson. He’s here to talk about his specific way of managing mental compulsions. As you may know, if you’ve listened before, I strongly urge you to start and go in order. So, first, we started with Mental Compulsions 101. That was with yours truly, myself. Then Jon Hershfield came in. He talked about mindfulness and really went in, gave some incredible tools. Shala Nicely, again, gave some lived experience and really the tools that worked for her. And I have just been mind-blown with both of their expertise. And it doesn’t stop there. We have amazing Dr. Jonathan Grayson today talking about all of the ways that he manages mental compulsions and how he brings specific concepts to help a client be motivated and lean into that response prevention and to reduce those mental compulsions. I am again blown away with how amazing and respectful and kind and knowledgeable these experts are. I just am overwhelmed with joy to share this with you.

Again, please remember this should not replace professional mental health care. We are here at CBT School, who is the host of this series. We’re here to provide you skills and tools, and resources specifically if you don’t have access to those resources. That is a huge part of our mission. So, even though we have ERP School – and that is an online course, you can take it from your home – we wanted to offer this freely because so many people are seeming to be misunderstanding mental compulsions, and it’s an area I really have been excited to share with you in this free series.

So, I’m not going to yammer on anymore. I’m going to let you hear the amazing wisdom of Jonathan Grayson. Have a wonderful day.

Kimberley: Welcome. I am so honored to have you here, Jon Grayson.

Jonathan: It is always a pleasure.

Kimberley: Okay. So, I actually am really, really interested to hear your point of view. As we go through a different episode, I actually am learning things. I thought I knew it all, but I’m learning and learning. So, I’m so excited to get your view on managing mental compulsions or how you address them. My first question is, do you call them mental compulsions, mental rituals, rumination? How do you frame it?

Jonathan: I’m never really too big on jargony, but mental compulsions are mental rituals. And I think that’s trying to-- and I think the thing about mental rituals is some people don’t know they have them. I mean, some people know, but some people will describe it as, “I just obsess, I don’t have rituals.” but then when you listen, they do. And the ritual part is trying to reassure themselves or convince themselves that whatever it is they’re worrying about isn’t. So, they have both the fear part like, “Oh my God, what if this is true? But wait, here’s why it’s not true. Now I know that’s not really true. But what if it is true?” So, that is what I would call mental compulsion or rituals.

Kimberley: Right. How do you-- let’s say you’re sitting across from a patient or a client they are doing either predominantly mental compulsions or that’s a huge part of the symptoms that they have. How would you address in your own way, teaching somebody how to manage mental compulsions?

Jonathan: I think there’s two answers to the question because I never have, and one has to do with what is the content, because I believe every set of mental rituals – I believe it for all forms of OCD, whether there’s a very strong behavioral component or it’s all mental – it has its own set of arguments that we’re going to use. Of course, when I talk about arguments, I know this will be a shock to you, but to me, it always has to do with coping with uncertainty, because I think the purpose of mental compulsions is to deny reality. That is, there is something I don’t want to be true and I keep trying to convince myself it’s not true. 

Now often it’s a low probability. But low probability is not no probability. Sometimes I have clients a little confused, saying like, “I tell myself it’s low probability,” and they actually feel better. Is that okay? And the answer is, it depends. If I’m trying to convince myself, I don’t have to worry about it because it’s a low probability, no, that’s a ritual. If I’m just saying it’s a low probability, I mean, way actually with OCD, it’s very easy because people don’t mind saying it’s low prob they. They like saying it’s low probability, but they don’t want the last sentence to be “But it might happen.” So, it’s like, as long as you’re answering “It might happen,” then you’re dealing with reality because everything is a low probability, even if it’s really small. 

So, one part has to do with the content. And I think for every set of obsessions, there is, what is the content they’re doing? I think in a more general way, the goal of treatment is basically accepting that low probability things might happen. I was recently saying to people that I hope the probability of nuclear war is no worse than that. It was as bad as likely as a worldwide pandemic. Some people would freak out like, “You think there’s going to be a war?” First of all, I know anything, but they were missing the point. It’s like, no, I really mean it’s as likely as a pandemic, which means it’s not likely. However, the thing about the pandemic, low probability things can happen. So yeah, we’re probably okay.

And so, the thing about acceptance that everyone hates is acceptance is second best. We spend so much time talking about how great acceptance is and I really think it’s a disservice in some respects to not point out what acceptance means because it almost always is. Here’s something you don’t want that you might have to live with. If I lose a loved one, we start in denial. And for me, denial is defined as I’m comparing life to a fantasy. I have a woman in a bad relationship and she thinks he really loves the guy, but it’s like, he’d be so good if only he would change X, Y, and Z. And of course, if he changed X, Y, and Z, he would be someone else. So, they’re in love with a fantasy. And when somebody dies, the fantasy is life would be better if they were here. It’s a fantasy because that’s never happening again. So, we have to get them to the point. 

And of course, the thing, the reason I mentioned death is it points out a really important thing about acceptance. You don’t get to just decide, “I’m going to accept.” I lose a loved one. I don’t care how or where you are. You’re starting in denial because you’re missing them and you want them there. And after about a year, if you’ve gone through mourning, you accept it. It’s not like you don’t care they’re gone. You can still cry. You can still miss them. But when you’re doing something you’re enjoying and in the present not comparing to what it would be with that person. 

So, acceptance, I’m pretty sure, always sucks. However, it’s better than fantasy because the fantasies never happen. So, it doesn’t matter if it’s likely or unlikely. It’s just a matter that this is your fear and the thing that’s hard for people to deal with fear is to cope with it. You’re going to say, “How would I try to live with the worst happening?” And people’s initial response to something is, “Yeah, but I don’t want that.” There are multiple reasons that we need to do acceptance. If I’m correct about denial, that’s comparing reality to fantasy. Well, not acceptance means what I want will never happen. So, for me to want that there’s no possibility something will occur is probably not true. I don’t care if it means that maybe this reality doesn’t exist and I’m going to wake up, and some of the things that discover I’ve created all of reality, there’s nothing. I don’t know that that’s likely, but I can’t prove it’s not likely. 

So, I think people go in circles. And you can hear it. The thing about the pandemic, you could hear the regular population denial. Because when I say it’s comparing reality to fantasy, a lot of times that sounds cool. And people don’t quite get what it means, but here are statements of denial early in the pandemic, “Well, this can’t go on more than a few weeks.” Honestly, at the beginning, I was like, “Of course, it’s going on for a few weeks. They have to have a vaccination. They’re telling us that’s two years down the road. This is going on for a long time.”

Kimberley: I was in team two weeks.

Jonathan: Yeah. “It can’t last. I can’t take it.” Saying “I can’t take it,” although you’re expressing the feeling like “I really hate this,” but including in the words “I can’t take it” is a fantasy as if you have a choice. And in a way, luckily, most people who say they can’t take it didn’t kill themselves. It’s proved that they can’t take it. They took it. They kept going on. It’s like, they didn’t want to imagine continuing to live that way. So, acceptance is like, “Yeah, this is going to happen. Yes, it can keep going.” How will you try to cope with the worst? And go on, I’ll shut up. You look like you want to say something.

Kimberley: No, no. I’m following you. I’m really enjoying this. I actually wrote down the word “cope” right at the beginning because I think that that’s such a keyword here. To stay out of the fantasy, would you say that’s true?

Jonathan: Well, yes. The worst might-- I mean, I always feel like if I’m doing therapy and if somebody has intolerance of uncertainty, they don’t like uncertainty, I have to treat that problem. And what I mean by that is we have a lot of therapists who impose their own feelings on the client. If I have a therapist that I have somebody who’s socially anxious and saying, “I’m afraid if I go in a room, some people won’t like me.” Almost every therapist is going to say, “Oh, well, that’s the fact, they might not like you.” But that same patient is like, “I’m afraid if I touch the doorknob, I’m going to get sick.” “Oh no, that won’t happen.” Well, that’s not the issue. Now therapist is-- if I have a problem of threat estimation, that’s fine, but that’s not it. I don’t want to know that it’s a low probability, I want no probability. So, we have to deal with the fact that this is what the person’s afraid of. This is what they fear. 

Somebody will say, “Well, but they don’t have cancer issue. Why should they worry about it?” But let’s face it. If they did have cancer, the focus would be coping with the fact they’re dying. And if they’re afraid of having cancer, I’d say the treatment is the same. Now, the only great thing is they probably won’t have cancer, so it’s not a fear they will have to probably deal with. They want to have the second part of it like, “And I’m dying.” But to be more prepared-- and I think what you’ve done wisely, like hearing that, yes, what you’ve done wisely is you’re talking about the fact that this is not just a nosy problem. This is a problem for everyone, coping with uncertainty. 

I hate to do a plug. It’s okay. It’s a while away. Actually, Liz McIngvale and I, we’re working on a book, talking about-- well, the book is partially-- and we’ll be doing some talks on it. We’re saying that ERP is not the gold standard of treatment for OCD. And we’re going to say that it’s not the gold standard because it’s lacking the gold. It really needs to be ERP plus gold. But that’s awkward because I like to be calling these initials. So, we want to use initials. Do you happen to know the chemical symbol for gold?

Kimberley: F-- no. FE is copper. 

Jonathan: No, that’s iron. 

Kimberley: Iron. 

Jonathan: Yeah. AU.

Kimberley: AU.

Jonathan: The gold standard of treatment--

Kimberley: Like Australia.

Jonathan: Well, no. ERP plus AU. AU as in Accepting Uncertainty.

Kimberley: Oh, my trap.

Jonathan: Yeah. It took me a while to work that around. 

Kimberley: Now you sure it’s not Australia. 

Jonathan: But our point is what we want to write. We want to write a book that’s not only about helping therapists deal with every presentation of OCD and how you deal with the uncertainty problem, but we’re also arguing that it’s a book for everyone that people can learn from OCD, a disorder that intolerance uncertainty is like the core. Because I always feel that our clients who get better, they’re not normal. They are better than normal because they’re coping with uncertainty, because the average person really doesn’t do that. Well, I mean, in the pandemic, you got to see how bad non-sufferers are. So, I think the core of coping with mental obsessions is this. Well, what if the worst happens? And so many people, “I don’t want to think it,” and that leaves us stuck because we’re not stupid. If you say to somebody-- if you get a phone call from police and they say your spouse has died, your first response is you’re just in this shock and you’re just like frozen. And for a lot of things that are bad, that’s the way people stop thinking. It’s like, “I don’t want to think about it.” The thing is, if the police make that call, something happens next. And life goes on. 

And back for clients, I often ask that in a sneaky way. What if this did happen? What would be next? What if he did have-- the doctor says, “Yeah, it can,” so I freak out. What does that look like? “I’d be screaming.” You’re in the doctor’s office, screaming. How long are you going to do that? And then you’re going to go home and you need dinner. What do you do the next day? And even though we’re going through something that sounds terribly scary, people oddly feel better after that. Now, this is first session. It’s not like they’ve done treatment, but they feel better because a statement that is true, you can’t do what you won’t imagine. And I don’t mean this as you would say, in the flowers and unicorns kind of way that you can do anything you can imagine. I do not mean that. But if you won’t even imagine it, you can’t do it. So, what would you do in X situation where it’s like, no. Well, it’s like the world is ending. When we imagine it, it’s not like it’s good. But it’s like, oh, because the feeling that accompanies acceptance is a down, depressing feeling like, “Oh, that could happen.” However, it’s not frantic. Denial is frantic. “That can’t happen. No, no.” Again, everything at least has some low probability. Some things are higher. You could have cancer, yes. Your family could die. Those things are like, they’re there. So, it’s not like I get the choice.

So, the statement of denial is frantic. The statement of acceptance is depressing, but it’s not frantic. And so, I don’t care how bad the disaster is. How would you try to cope? Because in most realities, that’s what you’re going to do. And I could pause at this moment because I don’t know if this would be the point where I would then be shifting to, well, what are the mental compulsives we’re talking about here? Because I think again, each one has its own set of arguments. You’ve heard my general thing. In some ways I think I’m reasonably good at applying it to myself. I think there’s some areas I haven’t been tested in. So, that’s nice. I hope I could be-- I know what I want is possible because I’ve seen people do it. Would I be one of those good people? I can only hope. But at least because I know people have done it, I know it’s possible. I like to believe-- go on, you. Yes.

Kimberley: What does that look like? Can you paint me a picture of a client who does well using this strategy at managing mental compulsions?

Jonathan: A client that I-- there’s a podcast on that, the OC stories, he was afraid of going crazy. And he had had this from age 19 to his late forties. And he had ERP, but ERP was always focused likely and we’re going to focus on going crazy and all this stuff. Know whatever explicit just said to him, the goal of treatment is for you to risk going crazy. I told him that the first session and he began to cry because he’s been spending more than 30 years trying to avoid this. And I’m saying, “Oh yeah, this might happen.” And many people really are able to accept. And I never talk about accepting uncertainty. I talk about learning to accept uncertainty. Because really, if I can talk to you-- if it’s just a decision, we’re done the first session. But most people are convinced of recession. It took about three months to help convince him. And he kept going back and forth. And so, convincing him, we went through a number of things to work on it. 

So, I’m describing it quickly, so it sounds simple. But remember, three months. The first reason, and this is true of almost all rituals, mental compulsions, regardless, you don’t have a choice. All your rituals do not prevent you from going crazy. He’s avoiding places because you’ve got an anxiety attack there, so I’m not going to go there. It’s like, sorry, it’s a biological process that you’re going crazy. That’s doing nothing. So, one is, your rituals don’t work. Two, for pretty much anything, you don’t have a choice. Uncertainty is the fact of life. We talked about what it would look like and he went crazy. And we were going-- and we talked about, well, what’s going to happen? Where are you going to go? He went through all these things. And because he’s logical, at some point it’s like, it could happen. 

And at that point, he’s then able to spend the other work, which is not fun, which is then imagining going crazy and looking at all the things that scare the heck out of him so he could begin to function again. We wanted to treat going crazy, the way most people do this is not their problem. Treat, getting main paralyzed and disfigured in a car crash. We all know it’s possible. Our brilliant plan is generally, I hope it doesn’t happen. I’m not dealing with it until I’m bleeding out, crushed under the metal. To say, “I’m not going to be in a car accident today,” it’s like, really? I can’t say that. So, our goal is to get whatever uncertainties in life there are to be like that. And it doesn’t matter whether I’m afraid of going crazy. I’m afraid that I’m going to be a pedophile. I’m going to slice and dice my wife tonight. I’m going to flunk the test. These people don’t like me. It doesn’t matter what it is. It’s still always the same. I mean, we can talk about odds, but not as simply reassurance because, again, it’s reassurance if I want to know it’s low odds, but if I want it to not be possible, it’s not reassuring. It’s like, it’s probably not this, but it might be how we deal with it is that way. 

The other thing that we look at is, how does it work for you to fight against this uncertainty? What are you losing? And of course, the more pathological the problem is, the worse it is. So, if I have OCD, it could be destroying my life. I’m not only hurting myself, I’m hurting my family. Let’s go how you’re really torturing everybody. And sometimes I think, in that case, we’re looking for reasons to get better. I always like people to look at all the harm they’re doing to themselves and their family. And I think in a brilliant way, just to plug you, I think your book, your new book really partially addresses that because the self-compassion part isn’t just like, okay, be nice to yourself, stop suffering. It’s like, if you’re going to love yourself, what kind of life do you want to make for yourself? What are your values going to be? Because I think we transform this process of coping into something more than simply confronting fear. It becomes something for myself. And secondarily, not as preferable, but sometimes easier to get to – it becomes not only confronting a fear, it becomes an act of love. Because you know what, I’m going to stop being a pain in the ass to my family. I’m now going to put all of us first. 

And so, we’re really going to have-- what are my values, and how does this interfere with my values? And again, it doesn’t have to be as major as I’m dysfunctional, torturing my family with something OCD for any worry. Everybody’s going to be happier if I can cope with my worries better. I mean, my family’s going to be happier because they love me. It’s really nice to see me not freaking out because they don’t have-- because you want to help and there’s no way to help. So, for me to be better and calmer and coping is nice for them. It’s certainly nice for me, and isn’t that what I would prefer in life? And so, when, when my life depends on me having a worry that’s not allowed to happen, I don’t get to enjoy things. 

Another coping thing I do that’s smaller is I will ask people to notice what they’re enjoying, no matter how, whatever level, even 5%. I think many times people will say, “Everything sucks, I don’t enjoy anything because of this problem.” Now that’s not entirely true because in the course of interviewing them, there are a few times I’ll get them to laugh for three seconds. And I admit if laughing three seconds were the goal, wow, that’d be great. But three seconds of laughter isn’t much compared to a life of misery. But the thing is, they don’t even notice that ever. The entire experience has been horrible and it’s like-- and to get them to notice not what it should be, but what it was. 

I once did this with a guy. I sent him to the movies and I said, “Watch the movie, just tell me whatever you enjoyed. I don’t care how little.” And he came back and he said, “It didn’t work. Everything was horrible.” I’m like, “Okay, now tell me about the movie.” So, he was describing the movie to me, it was a war movie, and it is clear, this guy liked the climax. So, I’m like--

Kimberley: Isn’t that funny? The way our brain works?

Jonathan: Yeah. And I said, “That was pretty cool, that climax. Are you sorry you saw that?” “No.” I said, “Okay, you didn’t do my assignment. Notice whatever you enjoyed. I don’t care that it’s not as good as it should have been. You clearly like that.” And it makes a difference because it means a two-hour experience that he comes away believing he had nothing. It would be a slight change to go like, “I enjoyed a little bit of that.” I try to tell people, think of it as like a little while of enjoyment that you don’t notice exists, and we want to expand those. And most people would recognize that in a way, what we’re talking about is a little bit of mindfulness. Like, okay, it sucks. I’m not arguing it doesn’t suck, but a lot of mindfulness. It isn’t like, I’m going to put you in a happy land. It’s like, we were trying to do AND, not OR.

The beginning of the pandemic, Kathy and I, we’re out on our pandemic walk. And she said to me, “This would be such a great day if all this wasn’t going on.” I said, “You’re wrong, Kathy.” We should let you and your listeners know. You don’t know this, but your husband does. Being married to a psychologist is not necessarily fun.

Kimberley: So true.

Jonathan: It is a beautiful day. We’re walking together, it’s beautiful. We’re together, it is beautiful. It is a beautiful day AND it sucks that there’s a pandemic. 

Kimberley: So true. 

Jonathan: Not OR, it’s AND. In a sense, mindfulness is teaching us to live in that world of AND. This is awful AND I can still enjoy stuff, as opposed to it’s either or. And again, some people go like, “Well, that’s awful.” And that’s perfectly true, because we’re going back to what is acceptance. Acceptance sucks. It’s the second-best life. However, what’s really great about the second-best life, the first best doesn’t exist. So, it’s like, yeah, it’s second-best, but it’s this or nothing. So, I think those are a lot of the principles of doing it and I think to do it, it’s like, why would I take this risk? It’s not a risk, but essentially, it’s like, why would I accept living like this, whatever this is? And I don’t have a choice. What am I losing by not living like this? Am I hurting my family? What would life be like if I could be okay with this? Depending who you are, that’s an incredibly amazing change or it’s a minor change. I mean, if I’m a very competent worrier and very successful, we’re talking about way more peace. But if I’m competent, I’m interfering with my life and taking up a lot of time, we’re now making major changes in the quality of life. And as you know, I can obsess or worry about anything from like, “I need to be the best.” And I always ask people, what is so good about best? Because God forbid, you should be mediocre. God forbid, you should be a happy mediocre person than the best person. And so, for some--

Kimberley: Well, that’s still a piece of denial, isn’t it? They have this idea that the best is no pain.

Jonathan: Yeah.

Kimberley: There’s no pain at the top.

Jonathan: Yeah. Right. And generally, there’s some other assumption that-- I don’t know. Somehow, I’m deficient of, I’m not best. So, it’s like the only way I can know. It’s another set of issues. What is it that I fear that I have to cope with? Not being best. Okay, I get you want to be best. Why? Well, best is best. I mean, it’s nice, I guess. When I think about being well-known, I generally think of being well-known as icing. That is, what makes my life great? For me, I love what I’m doing, and what I’m doing is, besides talking a lot because I love talking, but I like working with people, and I just really enjoy it. I have no plans on retiring because I like this too much. That’s almost all year round. Being famous and well-known, that’s about six days a year when I go to conventions. And I say, it’s like icing to indicate I am weak enough. I’ll admit I’m weak enough to really enjoy it. But I also recognize it is nothing. It doesn’t have any substance. And the thing about fame, you’re always going to lose it. You’re never famous enough. And there’s a poem by Shelly that I think really characterizes it. It describes a traveler in an ancient land. It’s come across a huge fallen monument and it’s describing the magnificence of what this had been. And he comes to the base of the statue where these words are written: “My name is Ozymandias, King of Kings; Look on my Works, ye Mighty, and despair!” That’s fame. It’s empty I can gorge, but it doesn’t mean anything because what I enjoy is what I actually do. It’d be sad if my life was like, it’s good six days a year when I can feel it.

Kimberley: Right. And I think what’s important, particularly for the sufferer, is you still have uncertainty in your life.

Jonathan: I don’t know any way to be certain, so I know nothing.

Kimberley: Right. You know what I was reflecting on, and this is just me reflecting, is last year, maybe it was the beginning of this year, I gave myself the exercise to catch the mini toddler tantrums that showed up in my mind.

Jonathan: I love that term. Great. Did you make that up?

Kimberley: I think I did because it--

Jonathan: Take credit. It’s great. Love it.

Kimberley: It feels like a toddler tantrum in my mind.

Jonathan: It’s perfect. It’s that “But I don’t want that.” I love it. Oh, I love it. Go on.

Kimberley: Yeah. I did a whole podcast about it last year because I was just noticing toddler tantrum after toddler tantrum, and I regulate myself really well. But it was showing up. And then as you’re talking, I’m thinking about how that was me resisting acceptance. That toddler tantrum is probably where I have the option to pull out of rumination and be present when I can catch it and be like, “Okay, you’re totally in denial. You’re in a fantasy land.” And so, that really speaks to me as a way to catch when you’re up in that place of rumination.

Jonathan: That’s perfect.

Kimberley: Yeah. For me, that was really powerful. I love that you brought that up because I think that is the bridge. I’m totally out of acceptance when I’m in a toddler tantrum.

Jonathan: Right. Because when you get better, as you’re describing, you can deal that pull of like, “This is what it is. No, no, no.” You can feel that pull back and forth because you don’t get completely lost and it’s like, ah.

Kimberley: Yeah. It was such a visual. I could see it tantruming out. “No, no, no.” And so, I love that you brought that in particularly in this way, like I said, of catching the compulsion. So, thank you. That actually consolidated--

Jonathan: I’m just now obsessing about how I’m going to work this in. We’ll give you credit.

Kimberley: You do. The Kimberly Quinlan “toddler tantrum,” I’m very well-known for it now. No, I am so thankful for you for bringing all this up. Is there-- because I want to be respectful of your time, is there anything else that you want to address when it comes to conceptualizing or managing mental compulsions?

Jonathan: I think that I’m afraid I have to be patient. Again, thinking about death, I don’t get to accept just because I want to. You have some people who try to accept like, “I’m accepting and I’m accepting it.” It’s like, yeah, sorry. I can be working towards learning it. I think sometimes people have an insight. An insight is not like you suddenly know some new piece of information. Insight is something that you basically knew, suddenly it’s true. I had somebody have that the other day when that’s hurting and they felt like it was trivial trying to explain to me what happened, but I already had this concept. I said, “I know. It’s like, you’ve always known you feel like going wrong.” “No, you don’t get it. It’s really true.” So, it was very cool. 

And so, I think it’s a gradual process where I get better at it. And because life is completely uncertain in every which way, there’s always opportunities to practice it, better personal. And you may scare other people. And one client who was very scared of a lot of things, especially of one of their pets dying. As they got uncertain and told, and then they could talk about it pretty calmly with people, “Oh yeah, I think she’s going to die at some point.” And people would be horrified. She could sound so calm, but she was like, not that she likes it and she really doesn’t want it to happen, but she could also think about it and think about life after that. And I think some people mistakenly will say something like, “Oh my God, you’re making life complete miserable. All you’re thinking about is all these nightmares that can happen all the time. That’s terrible.” That’s crazy because-- I thought I’d use a clinical term. Because what happens when I accept uncertainty? 

Somebody else has said this. Unfortunately, I haven’t made it up. I become, in a positive way, hopeless future. And what I mean by hopeless is the way most people who aren’t scared of the car crash, or it’s not like, I’m okay with a car crash. It’s like, what can I do? And when I become hopeless about control, that is when I get to live in the present because I’m no longer in the past or the future. Let’s face it. The truth is that’s all we have. The past of great memories or terrible memories, the future’s hopes, all we have is the present, this moment, my entire life and your entire life with each other. Everything else we like might not be there at this moment. So, I get to have the only thing there is, which is the present. And again, I can’t just decide because you see people do this, “I’m going to live in the present. I’m going to enjoy the present now. Enjoy the present.” It’s like, I have to learn to give things up. 

To steal from this woman who wrote this book of compassion: “To be kind to myself, to let myself learn, to not expect it all at once.” Again, if we were talking OCD, I don’t know why we were talking about that. If we were talking about OCD, every particular variation has its own uncertainties to cope with. Scrupulosity, how do I learn to believe in a God and simultaneously admit I might be wrong? How do I live in a world where probably I’m not going to slice and dice Kathy tonight? But if I do, how would I try to-- what would I do the next step?

When my son was 16 and going out on dates. And of course, he would never be home on time. And Kathy always wanted to call him. And I wouldn’t let her call him not to be nice to him, but I knew as she knew, his cell phone would be on. So, calling somebody you’re worried about in their cell phone on is not going to be comforting. So, she’d go like, “Well, when can I call him?” So, I’d make this mental calculation. Okay, he should be home now. I think he’ll be home in these many minutes. And let me add another half hour and say, you can call him dead. And she could for some reason, which is unusual, she would then go to sleep. And I would go there and I think, “Huh, he’s probably okay. He’s probably not doing anything terrible. Probably nothing terrible is happening to him. But tonight could be the night that our lives change and everything is screwed up forever.” And then I would go to sleep. That’s just the truth.

Kimberley: Yeah. It’s powerful. I’ll be calling you, and my kids are teenagers, saying “Coach me, coach me.”

Jonathan: Yeah. And I will give you the following advice. It gets so much easier when they’re 23. 

Kimberley: Yes, I know.

Jonathan: Until your acceptance is, “Oh yeah,” you’re screwed till then.

Kimberley: It’s true. I’m so grateful for you and your time and all your wisdom. I feel like I’m sitting and just absorbing it all for myself, which I’m loving. 

Jonathan: Thank you.

Kimberley: Tell us, I know you’ve been on the podcast before, but tell us where people can hear more about you and your work. You obviously have a new book, which I did not know about.

Jonathan: Well, we are working on it and we’re at the stage of working it, not procrastinating. We’re at the stage of doing a bunch of presentations on the idea, because I’ve just seen so many treatments fail because it didn’t address uncertainty. Although I always focus on certainty, it really is-- the bottom part of dealing with that is coping with life. It transcends OCD. So, I don’t know. What would you like to know about me?

Kimberley: Where can people find you?

Jonathan: Where can people find me? Easily on the internet. Website is a laocdtreatment.com. But I think my name plus OCD tends to come up a lot. 

Kimberley: Your book?

Jonathan: I have a book. It’s Freedom From OCD. I think there are a lot of good OCD books. Of course, I like mine because I agree with it most. But it’s a little scary when people read it before they see me because it is almost my entire repertoire minus maybe about 40 minutes. I feel like I’m going to be repeating myself, but somehow that doesn’t seem to be a problem. Apparently, hearing it out loud is different than reading it. 

Kimberley: Well, and that’s the whole point, right? I have the same situation as people need to hear it more than once too, in some cases. Not as a form of reassurance, but I think we all need to hear it. Even me today having a little light bulb moment I think is really cool, even though I’ve heard that before. So, I will have your website and your work in the show notes.

Jonathan: Very kind.

Kimberley: Thank you so much for being here and sharing.

Jonathan: I don’t know if you figured it out yet. I know I’ve told you this, but I’ll just repeat it. Probably if you asked me to come on, the answer will always be yes. So, thank you.

Kimberley: I’m so happy. No, I remember you saying that last time. Like I said to you, before we started recording, I have wanted to do this series for quite a while. And I had you right there going. I already put you on the list because I already knew. You told me you would say yes.

Jonathan: And so, apparently, I’m not dishonest or not that dishonest.

Kimberley: Not at all. When I texted to ask you, I actually already had you on the list and scheduled you in.

Jonathan: It was a confidence that you could well have.

Kimberley: Yeah. I’m so grateful. And yes, we will definitely have you on. It’s always a pleasure.

Jonathan: All right. Okay. Take care. Thank you very much.

May 13, 2022

SUMMARY: 

In this weeks podcast, we have my dearest friend Shala Nicely talking about how she manages mental compulsions.  In this episode, Shala shares her lived experience with Obsessive Compulsive Disorder and how she overcomes mental rituals.

In This Episode:

  • How to reduce mental compulsions for OCD and GAD.
  • How to use Flooding Techniques with Mental Compulsions
  • Magical Thinking and Mental Compulsions
  • BDD and Mental Compulsions

Links To Things I Talk About:

Shalanicely.com
Book: Is Fred in the Refridgerator?
Book: Everyday Mindfulness for OCD
ERP School: https://www.cbtschool.com/erp-school-lp

Episode Sponsor:

This episode of Your Anxiety Toolkit is brought to you by CBTschool.com.  CBTschool.com is a psychoeducation platform that provides courses and other online resources for people with anxiety, OCD, and Body-Focused Repetitive Behaviors.  Go to cbtschool.com to learn more.

Spread the love! Everyone needs tools for anxiety...

If you like Your Anxiety Toolkit Podcast, visit YOUR ANXIETY TOOLKIT PODCAST to subscribe free and you'll never miss an episode. And if you really like Your Anxiety Toolkit, I'd appreciate you telling a friend (maybe even two).

EPISODE TRANSCRIPTION

This is Your Anxiety Toolkit - Episode 284.

Welcome back, everybody. We are on the third video or the third part of this six-part series on how to manage mental compulsions. Last week’s episode with Jon Hershfield was bomb, like so good. And I will say that we, this week, have Shala Nicely, and she goes for it as well. So, I am so honored to have these amazing experts talking about mental compulsions, talking about what specific tools they use. 

So, I’m not going to take too much time of the intro this time, because I know you just want to get to the content. Again, I just want to put a disclaimer. This should not replace professional mental health care. This series is for educational purposes only. My job at CBT School is to give you as much education as I can, knowing that you may or may not have access to care or treatment in your own home. So, I’m hoping that this fills in a gap that maybe we’ve missed in the past in terms of we have ERP School, that’s an online course teaching you everything about ERP to get you started if you’re doing that on your own. But this is a bigger topic. This is an area that I’d need to make a complete new course. But instead of making a course, I’m bringing these experts to you for free, hopefully giving you the tools that you need. 

If you’re wanting additional information about ERP School, please go to CBTSchool.com. With that being said, let’s go straight over to this episode with Shala Nicely. 

Managing Mental Compulsions (With Shala Nicely) Your anxiety toolkit

Kimberley: Welcome, Shala. I am so happy to have you here.

Shala: I am so happy to be here. Thank you for having me.

Kimberley: Okay. So, I have heard a little bit of your views on this, but I am actually so excited now to get into the juicy details of how you address mental compulsions or mental rituals. First, I want to check in with you, do you call them mental compulsions, rituals, rumination? How do you address them?

Shala: Yeah. All those things. I also sometimes call it mental gymnastics up in your head, it’s all sorts of things you’re doing in your head to try to get some relief from anxiety.

Kimberley: Right. So, if you had a patient or a client who really was struggling with mental compulsions, whether or not they were doing other compulsions as well, how might you address that particular part of their symptomology?

Shala: So, let me answer that by stepping back a little bit and telling you about my own experience with this, because a lot of the way I do it is based on what I learned, trying to manage my own mental rituals. I’ve had OCD probably since I was five or six, untreated until I was 39. Stumbled upon the right treatment when I went to the IOCDF Conference and started doing exposure mostly on my own. I went to Reid Wilson’s two-day group, where I learned how to do it. But the rest of the time, I was implementing on my own. And even though I had quite a few physical compulsions, I would’ve considered myself a primary mental ritualizer, meaning if we look at the majority, my compulsions were up in my head. And the way I think about this is I think that sometimes if you have OCD for long enough, and you’ve got to go out and keep functioning in the world and you can’t do all these rituals so that people could see, because then people will be like, “What’s wrong with you? What are you doing?” you take them inward. And some mental compulsions can take the place of physical compulsions that you’re not able to do for whatever reason because you’re trying to function. And I’d had untreated OCD for so long that most of my rituals were up in my head, not all, but the great majority of them. 

Exposure & Response Prevention for Mental Compulsions

So, when I started to do exposure, what I found was I could do exposure therapy, straight up going and facing my fears, like going and being around things that might be triggering all I wanted, but I wasn’t necessarily getting better because I wasn’t addressing the mental rituals. So, basically, I’m doing exposure without response prevention or exposure with partial response prevention, which can make things either worse or just neutralize your efforts. So, what I did was I figured out how to be in the presence of triggers and not be up in my head, trying to do analyzing, justifying, figuring it out, replaying the situation with a different ending, all the sorts of things that I would do over and over in my head. And the way I did this was I took something I learned from Jonathan Grayson and his book, Freedom From OCD. I know you’re having him on for this series too. And he talked about doing all this ERP scripting, where you basically write out the worst-case scenario, what you think your OCD thinks is going to happen and you write it in either a worst-case way or an uncertainty-focused way. And what I did was after reading his book, I took that concept and I just shortened it down, and anything that my OCD was afraid of, I would just wrap may or may not surround it. 

So, for instance, an example that I use in Is Fred in the Refrigerator?, my memoir, Taming OCD and Reclaiming My Life was that I used to-- when I was walking through stores like Target, if I saw one of those little plastic price tags that had fallen on the ground, if I didn’t pick it up and put it out of harm’s way, I was afraid somebody was going to slip and fall and break their neck. And it would be on some security camera that I just walked on past it and didn’t do anything. So, a typical scrupulosity obsession. And so, going shopping was really hard because I’m cleaning up the store as I’m shopping. And so, what I would do is I would either go to Target, walk past the price tag. And then as I’m just passing the price tag, I would say things. And in Target, I obviously couldn’t do this really out loud, mumble it out loud as best, but I may or may not cause somebody to kill themselves by they’re going to slip and fall on that price tag because I didn’t pick it up. I may or may not be an awful, terrible rotten human being. They may or may not catch me and throw me into jail. I may or may not rot in prison. People may or may not find out what a really bad person I really am. This may or may not be OCD, et cetera, et cetera, et cetera. 

And that would allow me to be present with the obsessions, all the what-ifs – those are basically what-ifs turned into ‘may or may nots’ – without compulsing with them, without doing anything that would artificially lower my anxiety. So, it allowed me to be in the presence of those obsessive thoughts while interrupting the pattern of the mental rituals. And that’s really how I use ‘may or may nots’ and how I teach my clients to use ‘may or may nots’ today is using them to really be mindfully present of what the OCD is worried about while not interacting with that content in a way that’s going to make things worse. So, that’s how I developed it for myself. And I think that-- and that is a tool that I would say is an intermediary tool. So, I use that now in my own recovery. I don’t have to use ’may or may nots’. It’s very often at all. If I get super triggered, which doesn’t happen too terribly often, but if I get super triggered and I cannot get out of my head, I’ll use ’may or may nots’. 

But I think the continuum is that you try to do something to interrupt the mental rituals, which for me is the ’may or may nots’. You can also-- people can write down the scripts, they can do a worst-case scenario. But eventually, what you’re trying to get to is you’re trying to be able to hear the OCD, what-ifs in your head and completely ignore it. And I call that my shoulders back, the way of thinking about things. Just put your shoulders back and you move on with your day. You don’t acknowledge it. 

What I’ll do with clients, I’ll say, “If you had the thought of Blue Martian is going to land on my head, I mean, you wouldn’t even do anything with that thought. That thought would just go in and go out and wouldn’t get any of your attention.” That’s the way we want to treat OCD, is just thoughts can be there. I’m not going to say, “Oh, that’s my OCD.” I’m not going to say, “OCD, I’m not talking to you.” I’m not going to acknowledge it at all. I’m just going to treat it like any other weird thought that we have during the day and move on. 

Your question was, how would you help somebody who comes in with mental rituals? Well, first, I want to understand where are they in their OCD recovery? How long have they been doing these mental rituals? What percentage of their compulsions are mental versus physical? What are the kind of things that their OCD is afraid of? Basically, make a list or a hierarchy of everything they’re afraid of. And then we start working on exposure therapy. And when I have them do exposures, the first exposure I do with people, we’ll find something that’s-- I start in the middle of the hierarchy. You don’t have to, but I try. And I will have them face the fear. But then I’ll immediately ask them, what is your OCD saying right now? And they’ll tell me, and I’ll say, “I want you to repeat after me.” I have them do this, and everyone that I see hates this, but I have them do it. Standing up with their shoulders back like Wonder Woman, because this type of power pose helps them. It changes the chemistry of your body and helps you feel more powerful. 

OCD thinks it’s very powerful. So, I want my clients to feel as powerful as they can. So, I have them stand like Wonder Woman and they repeat after me. Somebody could-- let’s just say we are standing near something red on the floor. And I’ll say, “Well, what is your OCD saying right now?” And they’ll say, “Well, that’s blood and it could have AIDS in it, and I’m going to get sick.” I’ll say, “Well, that may or may not be a spot of blood on the floor. I may or may not get sick and I may or may not get AIDS, but I want to do this. I’m going to stay here. OCD, I want to be anxious, so bring it on.” 

And that’s how we do the exposure, is I ask them what’s in their head. I have them repeat it to me until they understand what the process is. And then I’m having them be in the presence of this and just script, script, script away. That’s what I call it scripting, so that they are in the presence of whatever’s bothering them, but they’re not up in their head. And anytime something comes in their head, I teach them to pull it down into the script. Never let something be circulating in your head without saying it out loud and pulling it into the script. 

I will work on this technique with clients as we’re working on exposures, because eventually what we’ll want to do is instead of going all over the place, “That may or may not be blood, I may or may not get AIDS, I may or may not get sick,” I’ll say, “Okay, of all the things you’ve just said, what does your OCD-- what is your OCD scared of the most? Let’s focus on that.” And so, “I may or may not get AIDS. I may or may not get AIDS. I may or may not have HIV. I may or may not get AIDS,” over again until people start to say, “Oh, okay. I guess I don’t have any control over this,” because what we’re trying to do is help the OCD habituate to the uncertainty. Habituate, I know that’d be a confusing word. You don’t have to habituate in order for exposure to work due to the theory of inhibitory learning, but we’re trying to help your brain get used to the uncertainty here.

Kimberley: And break into a different cycle instead of doing the old rumination cycle. 

Shala: Yes. And so then, I’ll teach people to just find their scariest fear. They say that over and over and over again. Then let’s hit the next one. “Well, my family may or may not survive if I die because if I get a fatal disease and I die and my family may or may not be left destitute,” and then over and over. “My family may or may not be left destitute. My family may or may not be left destitute, whatever,” until we’re hitting all the things that could be circulating in your head. 

Now, some people really don’t need to do that scripting because they’re not up in their head that much. But that’s the minority of people. I think most people with OCD are doing something in their head. And a lot of people aren’t aware of what they’re doing because these mental rituals are incredibly subtle at times. And so, as people, as my clients go out and work on these exposures, I’ll have them tell me how it’s going. I have people fill out forms on my website each day as they’re doing exposures so I can see what’s going on. And if they’re not really up in their head and they don’t really need to do the ‘may or may nots’, great. That’s better. In fact, just go do the exposure and go on with your life. If they’re up in their head, then I have them do the ’may or may nots’. And so, that’s how I would start with somebody. 

And so, what I’m trying to do is I’m giving them what I call a bridge tool. Because people who have been mental ritualizing for a long time, I have found it’s virtually impossible to just stop because that’s what your mind is used to doing. And so, what I’m doing is I’m giving them a competing response. And I’m saying here, instead of mental ritualizing, I’d like you to say a bunch of ’may or may nots’ statements while standing up and say them out loud while looking like Wonder Woman. Everybody rolls their eyes like, “Really?” But that’s what we do as a bridge tool. And so, they’ve lifted enough mental weights, so to speak, with this technique that they can hear the OCD and start to disengage and not interact with it at all. Then we move to that technique.

Flooding Techniques for Mental Rumination

Kimberley: Is there a reason why-- and for some of the listeners, they may have learned this before, but is there a reason why you use ’may or may nots’ instead of worst-case scenarios?

Shala: For me, for my personal OCD recovery journey, what I found with worst-case scenario is I got too lost in the content. I remember doing-- I had had a mammogram, it had come back with some abnormal findings. I spent the whole weekend trying to do scripting about what could happen, and I was using worst-case scenario. Well, I end up in the hospital, I end up with breast cancer, I end up dead. And by the end of the weekend, I was completely demoralized. And I’m like, “Well, I don’t bother because I’m going to be dead, because I have breast cancer.” That’s where my mind took it because I’ve had OCD long enough that if I get a really scary and I start and I play around in the content, I’m going to start losing insight and I’m going to start doing depression as a compulsion, which is the blog we did talk about, where you start acting depressed because you’re believing what the OCD says like, “Oh, well, I might as well just give up, I have breast cancer,” and then becoming depressed, and then acting like it’s true. And then that’s reinforcing the whole cycle. 

So, for me, worst-case scenario scripting made things worse. So, when I stayed in the uncertainty realm, the ‘may or may nots’ that helped because I was trying to help my brain understand, “Well, I may or may not have breast cancer. And if I do, I mean, I’ll go to the doctor, I’ll do what I need to do, but there’s nothing I can do about it right now in my head other than what I’m doing.”

Some people like worst-case scenario and it works fine for them. And I think that works too. I mostly use ’may or may nots’ with clients unless they are unable through numbing that they might be doing. If they’re unable to actually feel what they’re saying, because they’re used to turning it over in their head and pulling the anxiety down officially, and so I can’t get a rise out of the OCD because there’s a lot of really little subtle mental compulsions going on, then I’ll insert some worst-case scenario to get the anxiety level up, to help them really feel the fear, and then pull back into ’may or may nots’. But there’s nothing wrong with worst-case scenario. But for me, that was what happened. And I think if you are prone to depression, if you’re prone to losing insight into your OCD when you’ve got a really big one, I think that’s a risk factor for using that particular type of scripting. 

Magical Thinking and Mental Compulsions 

Kimberley: Right. And I found that they may or may not have worked just as well, except the one thing, and I’m actually curious on your opinion on this and I have not had this conversation, is I find that people who have a lot of magical thinking benefit by worst-case scenario, like their jinxing compulsions and so forth, like the fear of saying it means it will happen. So, saying the worst-case is the best exposure. Is that true for you?

Shala: I have not had to use it much on my own magically. I certainly had a lot of magical thinking. Like, if I don’t hit this green light, then somebody’s going to die. But I think the worst-case scenario, I could actually work well in that, because if you use the worst-case scenario, it can make it seem so ridiculous that it helps people let go of it more easily. And I think you can do that with ’may or may nots’ too. I’ll try to encourage people to use the creativity that they have because everybody with OCD has a ton of creativity. And we know that because the OCD shares your brain and it’s certainly the creative stuff

And to one-up the OCD, you use the scripting to be like, “Gosh, I may or may not get some drug-disease and give it to my entire neighborhood. I may or may not kill off an entire section of my county. We may or may not infect the entire state of Georgia. The entire United States may or may not blow up because I got this one disease. So, they may or may not have to eject me off the earth and make me live on Mars because I’m such a bad person.” This ‘may or may not’ is in all this crazy stuff too, because that’s how to win, is to one up the OCD. It thinks that’s scary, let’s go even scarier. But the scary you get, it also gets a little bit ridiculous after a while. And then the whole thing seems to be a little bit ridiculous. So, I think you can still use that worst-case stuff with may or may not.

Kimberley: Right. Okay. So, I mean, I will always sort of-- I know you really well. I’ve always held you so high in my mind in just how resilient and strong you are in doing this. How might you, or how do you help people who feel completely powerless at even addressing this? For you to say it, it sounds very like you’re just doing it and it’s so powerful. But for those who are really struggling with this idea of like, you said, coming out of your head, can you speak to how you address that in session if someone’s really struggling to engage in ’may or may nots’ and so forth?

Shala: Yeah. Well, thank you for the kind words, first off. I think that it’s really common for people with OCD by the time they get to a therapist to feel completely demoralized, especially if they’ve been to multiple therapists before they get to somebody who does ERP. And so, they feel like they’re the victim at the hands of a very cruel abuser that they can’t get away from. And so, they feel beaten down and they don’t know how to get out of their heads. They feel like they’re trapped in this mental prison. They can’t get out. And if somebody is struggling like that, and they’re doing the ’may or may nots’ and the OCD is reacting, which of course, it will, and coming back at them stronger, which I always warn people, this is going to happen. When you start poking at this, the OCD is going to poke back and poke back even harder, because it wants to get you back in line so it can keep you prisoner. 

So, what I’ll often do in those situations, if I see somebody is really feeling like they have been so victimized, that they’re never going to be able to get over this, is the type of script I have them do is more of an empowerment script, which could sound like this: “OCD, I’m not listening to you anymore. I’m not doing what you want. I am strong. I can do this.” And I might add some ’may or may nots’ in there. “And I want to be anxious. Come on, bring it on. You think that’s scary? Give me something else.” 

I know you’re having Reid Wilson on as part of this too. I learned all that “bring it on” type stuff and pushing for the anxiety from him. And I think helping people say that out loud can be really transformative. I’ve seen people just completely break down in tears of sort of, “Oh my gosh, I could do this,” like tears of empowerment from standing up and yelling at their OCD. 

If people like swearing, I also just have them swear at it, like they would really swear at somebody who had been abusing them if they had a chance, because swearing actually can make you feel more powerful too, and I want to use all the tools we can. So, I think scripting comes in a number of forms. It’s all about really taking what’s in your head, turning it into a helpful self-talk and saying it out loud. And the reason out loud is important for any type of scripting is that if you’re saying it in your head, it’s going to get mixed up with all the jumble of mental ruminating that’s going on. And saying it out loud makes it hard for you to ruminate. It’s not impossible, but it’s hard because you’re saying it. Your brain really is only processing one thing at a time. And so, if you’re talking and really paying attention to what you’re saying, it’s much harder to be up in your head spinning this around. 

And so, adding these empowerment scripts in with the ’may or may nots’ helps people both accept the uncertainty and feel like they can do this, feel like they can stand up to the OCD and say, “You’ve beaten me enough. No more. This is my life. I’m not letting you ruin it anymore. I am taking this back. I don’t care how long it takes. I don’t care what I have to do. I’m going to do this.” And that builds people up enough where they can feel like they can start approaching these exposures.

Kimberley: I love that. I think that is such-- I’ve had that same experience of how powerful empowerment can be in switching that behavior. It’s so important. Now, one thing I really want to ask you is, do you switch this method when you’re dealing with other anxiety disorders – health anxiety, social anxiety, panic disorder? What is your approach? Is there a difference or would you say the tools are the same?

Shala: There’s a slight difference between disorders. I think health anxiety, I treat exactly like OCD. Even some of the examples I gave here were really health anxiety statements. With panic disorder-- and again, I learned this from Reid and you can ask him more about this when you interview him. But with pain disorder, it’s all about, I want to feel more shorter breath, more like their elephant standing on my chest. I want my heart to be faster. But I’m doing this while I’m having people do exercises that would actually create those feelings, like breathing through a little bit of cocktail straw, jogging, turning up a space heater, and blowing it on themselves. So, we’re trying to create those symptoms and then talk out loud and say, “Come on, I want more of this. I want to feel more anxious. Give me the worst panic attack you’ve ever had.” So, it’s all about amping up the symptoms. 

With social anxiety, it’s a little bit different because with social anxiety, I would work on the cognitions first. Whereas with OCD, we don’t work on the cognitions at all, other than I want you to have a different cognitive relationship with your disorder and your anxiety. I want you to want the anxiety. I want you to want the OCD to come and bother you because that gives you an opportunity to practice. That’s the cognitive work with OCD. I do not work on the cognitive work on the content. I’m not going to say to somebody, “Well, the chance you’re going to get AIDS from that little spot of blood is very small.” That’s not going to be helpful 

With social anxiety, we’re actually working on those distorted cognitions at the beginning. And so, a lot of the work with social anxiety is going to be going out and testing those new cognitions, which really turns the exposures into what we call behavioral experiments. It’s more of a cognitive method. We’re going out and saying, “Gosh, my new belief, instead of everybody’s judging me, is, well, everybody is probably thinking about themselves and I’m going to go do some things that my social anxiety wouldn’t want me to do and test out that new belief.” I might have them use that new belief, but also if their anxiety gets really high and they’re having a hard time saying, “Well, that person may or may not be judging me. They may or may not be looking at me funny. They may or may not go home and tell people about me.” But really, we’re trying to do something a little bit different with social anxiety.

Kimberley: And what about with generalized anxiety? With the mental, a lot of rumination there, do you have a little shift in how you respond?

Shala: Yeah. So, it’s funny that the talk that Michelle Massi and others gave at IOCDF-- I think it was at IOCDF this year about what’s the difference between OCD and GAD is they’re really aligned there. I mean, I treat GAD very similarly the way I treat OCD in that people are up in their heads trying to do things. They’re also doing other types of safety behaviors, compulsive safety behaviors, but a lot of people GAD are just up in their head. They’re just worried about more “real-life” things. But again, a lot of OCD stuff can be real-life things. I mean, look at COVID. That was real life. And people’s OCD could wrap itself around that. So, I treat GAD and OCD quite similarly. There are some differences, but in terms of scripting, we call it “worry time” in GAD. It’s got a different name, but it’s basically the same thing.

Kimberley: Right. Okay. Thank you for answering that because I know some folks here listening will be not having OCD and will be curious to see how it affects them. So, is that the practice for you or is there anything else you feel like people need to know going in, in terms of like, “Here is my strategy, here is my plan to target mental rituals”? What would you say?

Shala: So, as I mentioned, I think the ’may or may nots’ are bridge tool that are always available to you throughout your entire recovery. My goal with anybody that I’m working with is to help them get to the point where they can just use shoulders back. And the way that I think about this is what I call my “man in the park” metaphor. So, we’ve all probably been in a park where somebody is yelling typically about the end of the world and all that stuff. And even if you were to agree with some of the things that the person might say from a spiritual or religious standpoint, you don’t run home and go, “Oh my gosh, we got to pack all our things up because it’s the end of the world. We have to get with all of our relatives and be together because we’re all going to die.” We don’t do that. We hear what this guy’s saying, and then we go on with our days, again, even if you might agree with some of the content.

Now, why do we do that? We do that because it’s not relevant in our life. We realize that person probably, unfortunately, has some problems. But it doesn’t affect us. We hear it just like when we might hear birds in the background or a car honking, and we just go on with our day. That’s how we want to treat OCD. What we do when we have untreated OCD is we run up to the man in the park and we say, “Oh my gosh, can I have a pamphlet? Let me read the pamphlet. Oh my gosh, you’re right. Tell me more, tell me more.” And we’re interacting with him, trying to get some reassurance that maybe he’s wrong, that maybe he does really mean the end of the world is coming soon. Maybe it’s going to be like in a hundred years. Eventually, we get to the point where we’re handing out pamphlets for him. “Here, everybody, take one of these.”

What we’re doing with ’may or may nots’ is we’re learning how to walk by the man in the park and go, “The world may or may not be ending. The world may or may not be ending. I’m not taking a pamphlet. The world may or may not be ending.” So, we’re trying to not interact with him. We’re trying to take what he’s saying and hold it in our heads without doing something compulsive that’s going to make our anxiety higher. What we’re trying to do is practice that enough till we can get to the point where we can be in the park with the guy and just go on with our day. We hear him speaking, but we’re really-- it’s just not relevant. It’s just not part of our life. So, we just move on. And we’re not trying to shove him away. It’s just like any other noise or sound or activity that you would just-- it doesn’t even register in your consciousness. That’s what we’re trying to do. 

Now I think another way to think about this is if you think-- say you’re in an art gallery. Art galleries are quiet and there are lots of people standing around, and there’s somebody in there that you don’t like or who doesn’t like you or whatever. You’re not going to walk up to that person and tap on their shoulder and say, “Excuse me, I’m going to ignore you.” You’re just going to be like, “I know that person is there. I’m just going to do what I’m doing.” And I think that’s-- I use that to help people understand this transition, because we’re basically going from ’may or may nots’ where we’re saying, “OCD, I’m not letting you do this to me anymore,” so we are being really aggressive with it, to this being able to be in the same space with it, but we’re not talking to it at all because we don’t need to, because we can be in the presence with the intrusive thoughts that the OCD is reacting to, just like the presence of all the other thousands of thoughts we have each day without interacting with them.

Kimberley: That’s so interesting. I’ve never thought of it that way. 

Shala: And so, that’s where I’m trying to get people because that is the strongest, strongest recovery, is if you can go do the things that you want to do, be in the presence of the anxiety and not do compulsions physical or mental, you don’t give anything for OCD to work with. I have a whole chapter in my memoir about this after I heard Reid say at one of the conferences, “We need to act as though what OCD is saying doesn’t matter.” And that was revolutionary to me to hear that. And that’s what we’re trying to do both physically and mentally. Because if you can have an obsession and focus on what you want to focus on, do what you want to do, you’re not giving OCD anything to work with. And typically, it’ll just drain away. But this takes time. I mean, it has taken me years to learn how to do this, but I went untreated for 35 years too. It may not take you years, but it may. And that’s okay. It’s a process. And I think if you have trouble trying to do shoulders back, man in the park, use ’may or may nots’. You can use the combination. But I think we’re trying to get to the point where you can just be with the OCD and hear it flipping out and just go on with your day.

OCD, BDD, and Mental Rituals 

Kimberley: In your book, you talk about the different voices. There is a BDD voice and an OCD voice. Was it harder or easier depending on the voice? Was that a component for you in that-- because the words and the voice sound a little different. I know in your memoir you give them different names and so forth, which if anyone hasn’t read your memoir, they need to go right now and read it. Do you have any thoughts on that in terms of the different voices or the different ways in which the disorders interact?

Shala: That’s a really great question because yes, I think OCD does shift its voice and shift its persona based on how scared it is. So, if it’s a little bit scared, it’s probably going to speak to you. It’s still going to be not a very nice voice. It might be urgent and pleading. But if it’s super scared, I talk about mine being like the triad of hell, how my OCD will personify into different things based on how scared it is. And if it’s super scared and it’s going to get super big and it’s going to get super loud in your head because it’s trying desperately to help you understand you’ve got to save it because it thinks it’s in danger. That’s all its content. Then I think-- and if you have trouble ignoring it because it’s screaming in your head, like the man in the park comes over with his megaphone, puts it right up against your ear and starts talking, that’s hard to ignore. That’s hard to act like that’s not relevant because it hurts. There’s so much noise. 

That’s when you might have to use a may or may not type approach because it’s just so loud, you can’t ignore it, because it’s so scared. And that’s okay. And again, sometimes I’ll have to use that. Not too terribly often just because I’ve spent a long time working on how to use the shoulder’s back, man in the park, but if I have to use it, I use it. And so, I think your thought about how do I interact with the OCD based on how aggressive it’s being also plays into this.

Kimberley: I love all this. I think this is really helpful in terms of being able to be flexible. I know sometimes we want just the one rule that’s going to work in all situations, but I think you’re right. I think that there needs to be different approaches. And would you say it depends on the person? Do you give them some autonomy over finding what works for them, or what would you say? 

Shala: Absolutely. If people are up in their heads and they don’t want to use ’may or may nots’, I’ll try to use some other things. If I really, really think that that’s what we need right now, is we need scripting, I’ll try to sell them on why. But at the end of the day, it’s always my client’s choice and I do it differently based on every client. For some clients, it might be just more empowering statements. For some clients where it’s more panicky focused, it might be more about bringing on your anxiety. Sometimes it might be pulling self-compassion in and just saying the self-compassion statements out loud. So, it really does vary by person. There’s no one-size-fits-all, but I think, I feel that people need to have something to replace the mental ritualizing with at the beginning that they’ve been doing it for a long time, just because otherwise, it’s like, I’m giving them a bicycle, they’ve never ridden a bicycle before and I won’t give them any training wheels. And that’s really, really hard. Some people can do it. I mean, some people can just be like, “Oh, I’m to stop doing that in my head? Okay, well, I’ll stop doing that in my head.” But most people need something to help them bridge that gap to get to the point where they can just be in the presence with it and not be talking to it in their heads.

Kimberley: Amazing. All right. Any final statements from you as we get close to the end?

Shala: I think that it’s important to, as you’re working on this, really think about what you’re doing in your head that might be subtle, that could be making the OCD worse. And I think talking and being willing to talk about this to therapists about putting it all out there, “Hey, I’m saying this to myself in my head, is that helpful or harmful?” Because OCD therapy can be pretty straightforward. I mean, ERP, go out and face your fears, don’t do rituals. It sounds pretty straightforward. But there is a lot of subtlety to this. And the more that you can root out these subtle mental rituals, the better that your recovery is going to be. 

And know too that if you’ve had untreated OCD for a long time, you can uncover mental rituals, little bitty ones, for years after you get out of therapy. And that’s okay. It doesn’t mean you’re not in recovery. It just means that you are getting more and more insightful and educated about what OCD is. And the more that you can pick those little things out, just the better your recovery will be. But we also don’t want to be perfectionistic about that like, “I must eliminate every single mental ritual that I have or I’m not going to be in a good recovery.” That’s approaching your ERP like OCD would do. And we don’t want to do that. But we do want to be mindful about the subtleties and make sure to try to pull out as many of those subtle things that we might be doing in our heads as possible. 

Kimberley: Amazing. Thank you. Tell us-- again, first, let me just say, such helpful information. And your personal experience, I think, is really validating and helpful to hear on those little nuances. Tell us where people can hear about you and the amazing projects you’ve got going on.

Shala: You can go to ShalaNicely.com and I have lots of free blog posts I’ve written on this. So, there are two blog posts, two pretty extensive blog posts on ’may or may nots’. So, if you go on my website and just search may or may not, it’ll bring up two blog posts about that. If you search on shoulders back or man in the park, you’ll find two blog posts on how to do that technique. I also have a blog post I wrote in the last year or so called Shower Scripting, which is how to do ERP, like just some touch-up scripting in the shower, use that time. So, I would say go to my website and you can find all sorts of free resources. I’ve got two books. You can find on Amazon, Everyday Mindfulness for OCD, Jon Hershfield and I co-wrote. And we talk about ‘may or may nots’ and shoulders back and some of the things in there just briefly. And then my memoir, Is Fred in the Refrigerator?: Taming OCD and Reclaiming My Life, is also on Amazon or bookstores, Audible, and that kind of thing. 

Kimberley: I wonder too, if we could-- I’m going to put links to all these in the show note. I remember you having a word with your OCD, a video?

Shala: Oh yes, that’s true.

Kimberley: Can we link that too?

Shala: Yes. And that one I have under my COVID resources, because I’m so glad you brought that up. When the pandemic started, my OCD did not like it, as many people who have contamination OCD can relate to. And it was pretty scary all the time. And it was making me scared all the time. And eventually, I just wrote it a letter and I’m like, “Dude, we’re not doing this anymore.” And I read it out loud and I recorded it out loud so that people could hear how I was talking to it. 

Kimberley: It was so powerful.

Shala: Well, thank you. And it’s fun to do. I think the more that you can personify your OCD, the more you can think of it as an entity that is within you but is not you, and to recognize that your relationship with it will change over time. Sometimes you’re going to be compassionate with it. “Gosh, OCD, I’m so sorry,” You’re scared we’re doing this anyway. Sometimes you’re going to be aggressive with it. Sometimes you just ignore it. And that changes as you go through therapy, it changes through your life. And I think that recognizing that it’s okay to have OCD and to have this little thing, I think of like an orange ball with big feet and sunglasses is how I think about it when it’s behaving – it makes it less of an adversarial relationship over time and more like I have an annoying little sibling that, gosh, it’s just not going to ever not be there, but it’s fine. We can live together and live in this uncertainty and be happy anyway.

Kimberley: I just love it. Thank you so much for being here and sharing your experience and your knowledge. It’s so wonderful.

Shala: Thank you so much for having me.

May 13, 2022

SUMMARY: 

In this weeks podcast, we have my dearest friend Shala Nicely talking about how she manages mental compulsions.  In this episode, Shala shares her lived experience with Obsessive Compulsive Disorder and how she overcomes mental rituals.

In This Episode:

  • How to reduce mental compulsions for OCD and GAD.
  • How to use Flooding Techniques with Mental Compulsions
  • Magical Thinking and Mental Compulsions
  • BDD and Mental Compulsions

Links To Things I Talk About:

Shalanicely.com
Book: Is Fred in the Refridgerator?
Book: Everyday Mindfulness for OCD
ERP School: https://www.cbtschool.com/erp-school-lp

Episode Sponsor:

This episode of Your Anxiety Toolkit is brought to you by CBTschool.com.  CBTschool.com is a psychoeducation platform that provides courses and other online resources for people with anxiety, OCD, and Body-Focused Repetitive Behaviors.  Go to cbtschool.com to learn more.

Spread the love! Everyone needs tools for anxiety...

If you like Your Anxiety Toolkit Podcast, visit YOUR ANXIETY TOOLKIT PODCAST to subscribe free and you'll never miss an episode. And if you really like Your Anxiety Toolkit, I'd appreciate you telling a friend (maybe even two).

EPISODE TRANSCRIPTION

This is Your Anxiety Toolkit - Episode 284.

Welcome back, everybody. We are on the third video or the third part of this six-part series on how to manage mental compulsions. Last week’s episode with Jon Hershfield was bomb, like so good. And I will say that we, this week, have Shala Nicely, and she goes for it as well. So, I am so honored to have these amazing experts talking about mental compulsions, talking about what specific tools they use. 

So, I’m not going to take too much time of the intro this time, because I know you just want to get to the content. Again, I just want to put a disclaimer. This should not replace professional mental health care. This series is for educational purposes only. My job at CBT School is to give you as much education as I can, knowing that you may or may not have access to care or treatment in your own home. So, I’m hoping that this fills in a gap that maybe we’ve missed in the past in terms of we have ERP School, that’s an online course teaching you everything about ERP to get you started if you’re doing that on your own. But this is a bigger topic. This is an area that I’d need to make a complete new course. But instead of making a course, I’m bringing these experts to you for free, hopefully giving you the tools that you need. 

If you’re wanting additional information about ERP School, please go to CBTSchool.com. With that being said, let’s go straight over to this episode with Shala Nicely. 

Managing Mental Compulsions (With Shala Nicely) Your anxiety toolkit

Kimberley: Welcome, Shala. I am so happy to have you here.

Shala: I am so happy to be here. Thank you for having me.

Kimberley: Okay. So, I have heard a little bit of your views on this, but I am actually so excited now to get into the juicy details of how you address mental compulsions or mental rituals. First, I want to check in with you, do you call them mental compulsions, rituals, rumination? How do you address them?

Shala: Yeah. All those things. I also sometimes call it mental gymnastics up in your head, it’s all sorts of things you’re doing in your head to try to get some relief from anxiety.

Kimberley: Right. So, if you had a patient or a client who really was struggling with mental compulsions, whether or not they were doing other compulsions as well, how might you address that particular part of their symptomology?

Shala: So, let me answer that by stepping back a little bit and telling you about my own experience with this, because a lot of the way I do it is based on what I learned, trying to manage my own mental rituals. I’ve had OCD probably since I was five or six, untreated until I was 39. Stumbled upon the right treatment when I went to the IOCDF Conference and started doing exposure mostly on my own. I went to Reid Wilson’s two-day group, where I learned how to do it. But the rest of the time, I was implementing on my own. And even though I had quite a few physical compulsions, I would’ve considered myself a primary mental ritualizer, meaning if we look at the majority, my compulsions were up in my head. And the way I think about this is I think that sometimes if you have OCD for long enough, and you’ve got to go out and keep functioning in the world and you can’t do all these rituals so that people could see, because then people will be like, “What’s wrong with you? What are you doing?” you take them inward. And some mental compulsions can take the place of physical compulsions that you’re not able to do for whatever reason because you’re trying to function. And I’d had untreated OCD for so long that most of my rituals were up in my head, not all, but the great majority of them. 

Exposure & Response Prevention for Mental Compulsions

So, when I started to do exposure, what I found was I could do exposure therapy, straight up going and facing my fears, like going and being around things that might be triggering all I wanted, but I wasn’t necessarily getting better because I wasn’t addressing the mental rituals. So, basically, I’m doing exposure without response prevention or exposure with partial response prevention, which can make things either worse or just neutralize your efforts. So, what I did was I figured out how to be in the presence of triggers and not be up in my head, trying to do analyzing, justifying, figuring it out, replaying the situation with a different ending, all the sorts of things that I would do over and over in my head. And the way I did this was I took something I learned from Jonathan Grayson and his book, Freedom From OCD. I know you’re having him on for this series too. And he talked about doing all this ERP scripting, where you basically write out the worst-case scenario, what you think your OCD thinks is going to happen and you write it in either a worst-case way or an uncertainty-focused way. And what I did was after reading his book, I took that concept and I just shortened it down, and anything that my OCD was afraid of, I would just wrap may or may not surround it. 

So, for instance, an example that I use in Is Fred in the Refrigerator?, my memoir, Taming OCD and Reclaiming My Life was that I used to-- when I was walking through stores like Target, if I saw one of those little plastic price tags that had fallen on the ground, if I didn’t pick it up and put it out of harm’s way, I was afraid somebody was going to slip and fall and break their neck. And it would be on some security camera that I just walked on past it and didn’t do anything. So, a typical scrupulosity obsession. And so, going shopping was really hard because I’m cleaning up the store as I’m shopping. And so, what I would do is I would either go to Target, walk past the price tag. And then as I’m just passing the price tag, I would say things. And in Target, I obviously couldn’t do this really out loud, mumble it out loud as best, but I may or may not cause somebody to kill themselves by they’re going to slip and fall on that price tag because I didn’t pick it up. I may or may not be an awful, terrible rotten human being. They may or may not catch me and throw me into jail. I may or may not rot in prison. People may or may not find out what a really bad person I really am. This may or may not be OCD, et cetera, et cetera, et cetera. 

And that would allow me to be present with the obsessions, all the what-ifs – those are basically what-ifs turned into ‘may or may nots’ – without compulsing with them, without doing anything that would artificially lower my anxiety. So, it allowed me to be in the presence of those obsessive thoughts while interrupting the pattern of the mental rituals. And that’s really how I use ‘may or may nots’ and how I teach my clients to use ‘may or may nots’ today is using them to really be mindfully present of what the OCD is worried about while not interacting with that content in a way that’s going to make things worse. So, that’s how I developed it for myself. And I think that-- and that is a tool that I would say is an intermediary tool. So, I use that now in my own recovery. I don’t have to use ’may or may nots’. It’s very often at all. If I get super triggered, which doesn’t happen too terribly often, but if I get super triggered and I cannot get out of my head, I’ll use ’may or may nots’. 

But I think the continuum is that you try to do something to interrupt the mental rituals, which for me is the ’may or may nots’. You can also-- people can write down the scripts, they can do a worst-case scenario. But eventually, what you’re trying to get to is you’re trying to be able to hear the OCD, what-ifs in your head and completely ignore it. And I call that my shoulders back, the way of thinking about things. Just put your shoulders back and you move on with your day. You don’t acknowledge it. 

What I’ll do with clients, I’ll say, “If you had the thought of Blue Martian is going to land on my head, I mean, you wouldn’t even do anything with that thought. That thought would just go in and go out and wouldn’t get any of your attention.” That’s the way we want to treat OCD, is just thoughts can be there. I’m not going to say, “Oh, that’s my OCD.” I’m not going to say, “OCD, I’m not talking to you.” I’m not going to acknowledge it at all. I’m just going to treat it like any other weird thought that we have during the day and move on. 

Your question was, how would you help somebody who comes in with mental rituals? Well, first, I want to understand where are they in their OCD recovery? How long have they been doing these mental rituals? What percentage of their compulsions are mental versus physical? What are the kind of things that their OCD is afraid of? Basically, make a list or a hierarchy of everything they’re afraid of. And then we start working on exposure therapy. And when I have them do exposures, the first exposure I do with people, we’ll find something that’s-- I start in the middle of the hierarchy. You don’t have to, but I try. And I will have them face the fear. But then I’ll immediately ask them, what is your OCD saying right now? And they’ll tell me, and I’ll say, “I want you to repeat after me.” I have them do this, and everyone that I see hates this, but I have them do it. Standing up with their shoulders back like Wonder Woman, because this type of power pose helps them. It changes the chemistry of your body and helps you feel more powerful. 

OCD thinks it’s very powerful. So, I want my clients to feel as powerful as they can. So, I have them stand like Wonder Woman and they repeat after me. Somebody could-- let’s just say we are standing near something red on the floor. And I’ll say, “Well, what is your OCD saying right now?” And they’ll say, “Well, that’s blood and it could have AIDS in it, and I’m going to get sick.” I’ll say, “Well, that may or may not be a spot of blood on the floor. I may or may not get sick and I may or may not get AIDS, but I want to do this. I’m going to stay here. OCD, I want to be anxious, so bring it on.” 

And that’s how we do the exposure, is I ask them what’s in their head. I have them repeat it to me until they understand what the process is. And then I’m having them be in the presence of this and just script, script, script away. That’s what I call it scripting, so that they are in the presence of whatever’s bothering them, but they’re not up in their head. And anytime something comes in their head, I teach them to pull it down into the script. Never let something be circulating in your head without saying it out loud and pulling it into the script. 

I will work on this technique with clients as we’re working on exposures, because eventually what we’ll want to do is instead of going all over the place, “That may or may not be blood, I may or may not get AIDS, I may or may not get sick,” I’ll say, “Okay, of all the things you’ve just said, what does your OCD-- what is your OCD scared of the most? Let’s focus on that.” And so, “I may or may not get AIDS. I may or may not get AIDS. I may or may not have HIV. I may or may not get AIDS,” over again until people start to say, “Oh, okay. I guess I don’t have any control over this,” because what we’re trying to do is help the OCD habituate to the uncertainty. Habituate, I know that’d be a confusing word. You don’t have to habituate in order for exposure to work due to the theory of inhibitory learning, but we’re trying to help your brain get used to the uncertainty here.

Kimberley: And break into a different cycle instead of doing the old rumination cycle. 

Shala: Yes. And so then, I’ll teach people to just find their scariest fear. They say that over and over and over again. Then let’s hit the next one. “Well, my family may or may not survive if I die because if I get a fatal disease and I die and my family may or may not be left destitute,” and then over and over. “My family may or may not be left destitute. My family may or may not be left destitute, whatever,” until we’re hitting all the things that could be circulating in your head. 

Now, some people really don’t need to do that scripting because they’re not up in their head that much. But that’s the minority of people. I think most people with OCD are doing something in their head. And a lot of people aren’t aware of what they’re doing because these mental rituals are incredibly subtle at times. And so, as people, as my clients go out and work on these exposures, I’ll have them tell me how it’s going. I have people fill out forms on my website each day as they’re doing exposures so I can see what’s going on. And if they’re not really up in their head and they don’t really need to do the ‘may or may nots’, great. That’s better. In fact, just go do the exposure and go on with your life. If they’re up in their head, then I have them do the ’may or may nots’. And so, that’s how I would start with somebody. 

And so, what I’m trying to do is I’m giving them what I call a bridge tool. Because people who have been mental ritualizing for a long time, I have found it’s virtually impossible to just stop because that’s what your mind is used to doing. And so, what I’m doing is I’m giving them a competing response. And I’m saying here, instead of mental ritualizing, I’d like you to say a bunch of ’may or may nots’ statements while standing up and say them out loud while looking like Wonder Woman. Everybody rolls their eyes like, “Really?” But that’s what we do as a bridge tool. And so, they’ve lifted enough mental weights, so to speak, with this technique that they can hear the OCD and start to disengage and not interact with it at all. Then we move to that technique.

Flooding Techniques for Mental Rumination

Kimberley: Is there a reason why-- and for some of the listeners, they may have learned this before, but is there a reason why you use ’may or may nots’ instead of worst-case scenarios?

Shala: For me, for my personal OCD recovery journey, what I found with worst-case scenario is I got too lost in the content. I remember doing-- I had had a mammogram, it had come back with some abnormal findings. I spent the whole weekend trying to do scripting about what could happen, and I was using worst-case scenario. Well, I end up in the hospital, I end up with breast cancer, I end up dead. And by the end of the weekend, I was completely demoralized. And I’m like, “Well, I don’t bother because I’m going to be dead, because I have breast cancer.” That’s where my mind took it because I’ve had OCD long enough that if I get a really scary and I start and I play around in the content, I’m going to start losing insight and I’m going to start doing depression as a compulsion, which is the blog we did talk about, where you start acting depressed because you’re believing what the OCD says like, “Oh, well, I might as well just give up, I have breast cancer,” and then becoming depressed, and then acting like it’s true. And then that’s reinforcing the whole cycle. 

So, for me, worst-case scenario scripting made things worse. So, when I stayed in the uncertainty realm, the ‘may or may nots’ that helped because I was trying to help my brain understand, “Well, I may or may not have breast cancer. And if I do, I mean, I’ll go to the doctor, I’ll do what I need to do, but there’s nothing I can do about it right now in my head other than what I’m doing.”

Some people like worst-case scenario and it works fine for them. And I think that works too. I mostly use ’may or may nots’ with clients unless they are unable through numbing that they might be doing. If they’re unable to actually feel what they’re saying, because they’re used to turning it over in their head and pulling the anxiety down officially, and so I can’t get a rise out of the OCD because there’s a lot of really little subtle mental compulsions going on, then I’ll insert some worst-case scenario to get the anxiety level up, to help them really feel the fear, and then pull back into ’may or may nots’. But there’s nothing wrong with worst-case scenario. But for me, that was what happened. And I think if you are prone to depression, if you’re prone to losing insight into your OCD when you’ve got a really big one, I think that’s a risk factor for using that particular type of scripting. 

Magical Thinking and Mental Compulsions 

Kimberley: Right. And I found that they may or may not have worked just as well, except the one thing, and I’m actually curious on your opinion on this and I have not had this conversation, is I find that people who have a lot of magical thinking benefit by worst-case scenario, like their jinxing compulsions and so forth, like the fear of saying it means it will happen. So, saying the worst-case is the best exposure. Is that true for you?

Shala: I have not had to use it much on my own magically. I certainly had a lot of magical thinking. Like, if I don’t hit this green light, then somebody’s going to die. But I think the worst-case scenario, I could actually work well in that, because if you use the worst-case scenario, it can make it seem so ridiculous that it helps people let go of it more easily. And I think you can do that with ’may or may nots’ too. I’ll try to encourage people to use the creativity that they have because everybody with OCD has a ton of creativity. And we know that because the OCD shares your brain and it’s certainly the creative stuff

And to one-up the OCD, you use the scripting to be like, “Gosh, I may or may not get some drug-disease and give it to my entire neighborhood. I may or may not kill off an entire section of my county. We may or may not infect the entire state of Georgia. The entire United States may or may not blow up because I got this one disease. So, they may or may not have to eject me off the earth and make me live on Mars because I’m such a bad person.” This ‘may or may not’ is in all this crazy stuff too, because that’s how to win, is to one up the OCD. It thinks that’s scary, let’s go even scarier. But the scary you get, it also gets a little bit ridiculous after a while. And then the whole thing seems to be a little bit ridiculous. So, I think you can still use that worst-case stuff with may or may not.

Kimberley: Right. Okay. So, I mean, I will always sort of-- I know you really well. I’ve always held you so high in my mind in just how resilient and strong you are in doing this. How might you, or how do you help people who feel completely powerless at even addressing this? For you to say it, it sounds very like you’re just doing it and it’s so powerful. But for those who are really struggling with this idea of like, you said, coming out of your head, can you speak to how you address that in session if someone’s really struggling to engage in ’may or may nots’ and so forth?

Shala: Yeah. Well, thank you for the kind words, first off. I think that it’s really common for people with OCD by the time they get to a therapist to feel completely demoralized, especially if they’ve been to multiple therapists before they get to somebody who does ERP. And so, they feel like they’re the victim at the hands of a very cruel abuser that they can’t get away from. And so, they feel beaten down and they don’t know how to get out of their heads. They feel like they’re trapped in this mental prison. They can’t get out. And if somebody is struggling like that, and they’re doing the ’may or may nots’ and the OCD is reacting, which of course, it will, and coming back at them stronger, which I always warn people, this is going to happen. When you start poking at this, the OCD is going to poke back and poke back even harder, because it wants to get you back in line so it can keep you prisoner. 

So, what I’ll often do in those situations, if I see somebody is really feeling like they have been so victimized, that they’re never going to be able to get over this, is the type of script I have them do is more of an empowerment script, which could sound like this: “OCD, I’m not listening to you anymore. I’m not doing what you want. I am strong. I can do this.” And I might add some ’may or may nots’ in there. “And I want to be anxious. Come on, bring it on. You think that’s scary? Give me something else.” 

I know you’re having Reid Wilson on as part of this too. I learned all that “bring it on” type stuff and pushing for the anxiety from him. And I think helping people say that out loud can be really transformative. I’ve seen people just completely break down in tears of sort of, “Oh my gosh, I could do this,” like tears of empowerment from standing up and yelling at their OCD. 

If people like swearing, I also just have them swear at it, like they would really swear at somebody who had been abusing them if they had a chance, because swearing actually can make you feel more powerful too, and I want to use all the tools we can. So, I think scripting comes in a number of forms. It’s all about really taking what’s in your head, turning it into a helpful self-talk and saying it out loud. And the reason out loud is important for any type of scripting is that if you’re saying it in your head, it’s going to get mixed up with all the jumble of mental ruminating that’s going on. And saying it out loud makes it hard for you to ruminate. It’s not impossible, but it’s hard because you’re saying it. Your brain really is only processing one thing at a time. And so, if you’re talking and really paying attention to what you’re saying, it’s much harder to be up in your head spinning this around. 

And so, adding these empowerment scripts in with the ’may or may nots’ helps people both accept the uncertainty and feel like they can do this, feel like they can stand up to the OCD and say, “You’ve beaten me enough. No more. This is my life. I’m not letting you ruin it anymore. I am taking this back. I don’t care how long it takes. I don’t care what I have to do. I’m going to do this.” And that builds people up enough where they can feel like they can start approaching these exposures.

Kimberley: I love that. I think that is such-- I’ve had that same experience of how powerful empowerment can be in switching that behavior. It’s so important. Now, one thing I really want to ask you is, do you switch this method when you’re dealing with other anxiety disorders – health anxiety, social anxiety, panic disorder? What is your approach? Is there a difference or would you say the tools are the same?

Shala: There’s a slight difference between disorders. I think health anxiety, I treat exactly like OCD. Even some of the examples I gave here were really health anxiety statements. With panic disorder-- and again, I learned this from Reid and you can ask him more about this when you interview him. But with pain disorder, it’s all about, I want to feel more shorter breath, more like their elephant standing on my chest. I want my heart to be faster. But I’m doing this while I’m having people do exercises that would actually create those feelings, like breathing through a little bit of cocktail straw, jogging, turning up a space heater, and blowing it on themselves. So, we’re trying to create those symptoms and then talk out loud and say, “Come on, I want more of this. I want to feel more anxious. Give me the worst panic attack you’ve ever had.” So, it’s all about amping up the symptoms. 

With social anxiety, it’s a little bit different because with social anxiety, I would work on the cognitions first. Whereas with OCD, we don’t work on the cognitions at all, other than I want you to have a different cognitive relationship with your disorder and your anxiety. I want you to want the anxiety. I want you to want the OCD to come and bother you because that gives you an opportunity to practice. That’s the cognitive work with OCD. I do not work on the cognitive work on the content. I’m not going to say to somebody, “Well, the chance you’re going to get AIDS from that little spot of blood is very small.” That’s not going to be helpful 

With social anxiety, we’re actually working on those distorted cognitions at the beginning. And so, a lot of the work with social anxiety is going to be going out and testing those new cognitions, which really turns the exposures into what we call behavioral experiments. It’s more of a cognitive method. We’re going out and saying, “Gosh, my new belief, instead of everybody’s judging me, is, well, everybody is probably thinking about themselves and I’m going to go do some things that my social anxiety wouldn’t want me to do and test out that new belief.” I might have them use that new belief, but also if their anxiety gets really high and they’re having a hard time saying, “Well, that person may or may not be judging me. They may or may not be looking at me funny. They may or may not go home and tell people about me.” But really, we’re trying to do something a little bit different with social anxiety.

Kimberley: And what about with generalized anxiety? With the mental, a lot of rumination there, do you have a little shift in how you respond?

Shala: Yeah. So, it’s funny that the talk that Michelle Massi and others gave at IOCDF-- I think it was at IOCDF this year about what’s the difference between OCD and GAD is they’re really aligned there. I mean, I treat GAD very similarly the way I treat OCD in that people are up in their heads trying to do things. They’re also doing other types of safety behaviors, compulsive safety behaviors, but a lot of people GAD are just up in their head. They’re just worried about more “real-life” things. But again, a lot of OCD stuff can be real-life things. I mean, look at COVID. That was real life. And people’s OCD could wrap itself around that. So, I treat GAD and OCD quite similarly. There are some differences, but in terms of scripting, we call it “worry time” in GAD. It’s got a different name, but it’s basically the same thing.

Kimberley: Right. Okay. Thank you for answering that because I know some folks here listening will be not having OCD and will be curious to see how it affects them. So, is that the practice for you or is there anything else you feel like people need to know going in, in terms of like, “Here is my strategy, here is my plan to target mental rituals”? What would you say?

Shala: So, as I mentioned, I think the ’may or may nots’ are bridge tool that are always available to you throughout your entire recovery. My goal with anybody that I’m working with is to help them get to the point where they can just use shoulders back. And the way that I think about this is what I call my “man in the park” metaphor. So, we’ve all probably been in a park where somebody is yelling typically about the end of the world and all that stuff. And even if you were to agree with some of the things that the person might say from a spiritual or religious standpoint, you don’t run home and go, “Oh my gosh, we got to pack all our things up because it’s the end of the world. We have to get with all of our relatives and be together because we’re all going to die.” We don’t do that. We hear what this guy’s saying, and then we go on with our days, again, even if you might agree with some of the content.

Now, why do we do that? We do that because it’s not relevant in our life. We realize that person probably, unfortunately, has some problems. But it doesn’t affect us. We hear it just like when we might hear birds in the background or a car honking, and we just go on with our day. That’s how we want to treat OCD. What we do when we have untreated OCD is we run up to the man in the park and we say, “Oh my gosh, can I have a pamphlet? Let me read the pamphlet. Oh my gosh, you’re right. Tell me more, tell me more.” And we’re interacting with him, trying to get some reassurance that maybe he’s wrong, that maybe he does really mean the end of the world is coming soon. Maybe it’s going to be like in a hundred years. Eventually, we get to the point where we’re handing out pamphlets for him. “Here, everybody, take one of these.”

What we’re doing with ’may or may nots’ is we’re learning how to walk by the man in the park and go, “The world may or may not be ending. The world may or may not be ending. I’m not taking a pamphlet. The world may or may not be ending.” So, we’re trying to not interact with him. We’re trying to take what he’s saying and hold it in our heads without doing something compulsive that’s going to make our anxiety higher. What we’re trying to do is practice that enough till we can get to the point where we can be in the park with the guy and just go on with our day. We hear him speaking, but we’re really-- it’s just not relevant. It’s just not part of our life. So, we just move on. And we’re not trying to shove him away. It’s just like any other noise or sound or activity that you would just-- it doesn’t even register in your consciousness. That’s what we’re trying to do. 

Now I think another way to think about this is if you think-- say you’re in an art gallery. Art galleries are quiet and there are lots of people standing around, and there’s somebody in there that you don’t like or who doesn’t like you or whatever. You’re not going to walk up to that person and tap on their shoulder and say, “Excuse me, I’m going to ignore you.” You’re just going to be like, “I know that person is there. I’m just going to do what I’m doing.” And I think that’s-- I use that to help people understand this transition, because we’re basically going from ’may or may nots’ where we’re saying, “OCD, I’m not letting you do this to me anymore,” so we are being really aggressive with it, to this being able to be in the same space with it, but we’re not talking to it at all because we don’t need to, because we can be in the presence with the intrusive thoughts that the OCD is reacting to, just like the presence of all the other thousands of thoughts we have each day without interacting with them.

Kimberley: That’s so interesting. I’ve never thought of it that way. 

Shala: And so, that’s where I’m trying to get people because that is the strongest, strongest recovery, is if you can go do the things that you want to do, be in the presence of the anxiety and not do compulsions physical or mental, you don’t give anything for OCD to work with. I have a whole chapter in my memoir about this after I heard Reid say at one of the conferences, “We need to act as though what OCD is saying doesn’t matter.” And that was revolutionary to me to hear that. And that’s what we’re trying to do both physically and mentally. Because if you can have an obsession and focus on what you want to focus on, do what you want to do, you’re not giving OCD anything to work with. And typically, it’ll just drain away. But this takes time. I mean, it has taken me years to learn how to do this, but I went untreated for 35 years too. It may not take you years, but it may. And that’s okay. It’s a process. And I think if you have trouble trying to do shoulders back, man in the park, use ’may or may nots’. You can use the combination. But I think we’re trying to get to the point where you can just be with the OCD and hear it flipping out and just go on with your day.

OCD, BDD, and Mental Rituals 

Kimberley: In your book, you talk about the different voices. There is a BDD voice and an OCD voice. Was it harder or easier depending on the voice? Was that a component for you in that-- because the words and the voice sound a little different. I know in your memoir you give them different names and so forth, which if anyone hasn’t read your memoir, they need to go right now and read it. Do you have any thoughts on that in terms of the different voices or the different ways in which the disorders interact?

Shala: That’s a really great question because yes, I think OCD does shift its voice and shift its persona based on how scared it is. So, if it’s a little bit scared, it’s probably going to speak to you. It’s still going to be not a very nice voice. It might be urgent and pleading. But if it’s super scared, I talk about mine being like the triad of hell, how my OCD will personify into different things based on how scared it is. And if it’s super scared and it’s going to get super big and it’s going to get super loud in your head because it’s trying desperately to help you understand you’ve got to save it because it thinks it’s in danger. That’s all its content. Then I think-- and if you have trouble ignoring it because it’s screaming in your head, like the man in the park comes over with his megaphone, puts it right up against your ear and starts talking, that’s hard to ignore. That’s hard to act like that’s not relevant because it hurts. There’s so much noise. 

That’s when you might have to use a may or may not type approach because it’s just so loud, you can’t ignore it, because it’s so scared. And that’s okay. And again, sometimes I’ll have to use that. Not too terribly often just because I’ve spent a long time working on how to use the shoulder’s back, man in the park, but if I have to use it, I use it. And so, I think your thought about how do I interact with the OCD based on how aggressive it’s being also plays into this.

Kimberley: I love all this. I think this is really helpful in terms of being able to be flexible. I know sometimes we want just the one rule that’s going to work in all situations, but I think you’re right. I think that there needs to be different approaches. And would you say it depends on the person? Do you give them some autonomy over finding what works for them, or what would you say? 

Shala: Absolutely. If people are up in their heads and they don’t want to use ’may or may nots’, I’ll try to use some other things. If I really, really think that that’s what we need right now, is we need scripting, I’ll try to sell them on why. But at the end of the day, it’s always my client’s choice and I do it differently based on every client. For some clients, it might be just more empowering statements. For some clients where it’s more panicky focused, it might be more about bringing on your anxiety. Sometimes it might be pulling self-compassion in and just saying the self-compassion statements out loud. So, it really does vary by person. There’s no one-size-fits-all, but I think, I feel that people need to have something to replace the mental ritualizing with at the beginning that they’ve been doing it for a long time, just because otherwise, it’s like, I’m giving them a bicycle, they’ve never ridden a bicycle before and I won’t give them any training wheels. And that’s really, really hard. Some people can do it. I mean, some people can just be like, “Oh, I’m to stop doing that in my head? Okay, well, I’ll stop doing that in my head.” But most people need something to help them bridge that gap to get to the point where they can just be in the presence with it and not be talking to it in their heads.

Kimberley: Amazing. All right. Any final statements from you as we get close to the end?

Shala: I think that it’s important to, as you’re working on this, really think about what you’re doing in your head that might be subtle, that could be making the OCD worse. And I think talking and being willing to talk about this to therapists about putting it all out there, “Hey, I’m saying this to myself in my head, is that helpful or harmful?” Because OCD therapy can be pretty straightforward. I mean, ERP, go out and face your fears, don’t do rituals. It sounds pretty straightforward. But there is a lot of subtlety to this. And the more that you can root out these subtle mental rituals, the better that your recovery is going to be. 

And know too that if you’ve had untreated OCD for a long time, you can uncover mental rituals, little bitty ones, for years after you get out of therapy. And that’s okay. It doesn’t mean you’re not in recovery. It just means that you are getting more and more insightful and educated about what OCD is. And the more that you can pick those little things out, just the better your recovery will be. But we also don’t want to be perfectionistic about that like, “I must eliminate every single mental ritual that I have or I’m not going to be in a good recovery.” That’s approaching your ERP like OCD would do. And we don’t want to do that. But we do want to be mindful about the subtleties and make sure to try to pull out as many of those subtle things that we might be doing in our heads as possible. 

Kimberley: Amazing. Thank you. Tell us-- again, first, let me just say, such helpful information. And your personal experience, I think, is really validating and helpful to hear on those little nuances. Tell us where people can hear about you and the amazing projects you’ve got going on.

Shala: You can go to ShalaNicely.com and I have lots of free blog posts I’ve written on this. So, there are two blog posts, two pretty extensive blog posts on ’may or may nots’. So, if you go on my website and just search may or may not, it’ll bring up two blog posts about that. If you search on shoulders back or man in the park, you’ll find two blog posts on how to do that technique. I also have a blog post I wrote in the last year or so called Shower Scripting, which is how to do ERP, like just some touch-up scripting in the shower, use that time. So, I would say go to my website and you can find all sorts of free resources. I’ve got two books. You can find on Amazon, Everyday Mindfulness for OCD, Jon Hershfield and I co-wrote. And we talk about ‘may or may nots’ and shoulders back and some of the things in there just briefly. And then my memoir, Is Fred in the Refrigerator?: Taming OCD and Reclaiming My Life, is also on Amazon or bookstores, Audible, and that kind of thing. 

Kimberley: I wonder too, if we could-- I’m going to put links to all these in the show note. I remember you having a word with your OCD, a video?

Shala: Oh yes, that’s true.

Kimberley: Can we link that too?

Shala: Yes. And that one I have under my COVID resources, because I’m so glad you brought that up. When the pandemic started, my OCD did not like it, as many people who have contamination OCD can relate to. And it was pretty scary all the time. And it was making me scared all the time. And eventually, I just wrote it a letter and I’m like, “Dude, we’re not doing this anymore.” And I read it out loud and I recorded it out loud so that people could hear how I was talking to it. 

Kimberley: It was so powerful.

Shala: Well, thank you. And it’s fun to do. I think the more that you can personify your OCD, the more you can think of it as an entity that is within you but is not you, and to recognize that your relationship with it will change over time. Sometimes you’re going to be compassionate with it. “Gosh, OCD, I’m so sorry,” You’re scared we’re doing this anyway. Sometimes you’re going to be aggressive with it. Sometimes you just ignore it. And that changes as you go through therapy, it changes through your life. And I think that recognizing that it’s okay to have OCD and to have this little thing, I think of like an orange ball with big feet and sunglasses is how I think about it when it’s behaving – it makes it less of an adversarial relationship over time and more like I have an annoying little sibling that, gosh, it’s just not going to ever not be there, but it’s fine. We can live together and live in this uncertainty and be happy anyway.

Kimberley: I just love it. Thank you so much for being here and sharing your experience and your knowledge. It’s so wonderful.

Shala: Thank you so much for having me.

May 13, 2022

SUMMARY: 

In this weeks podcast, we have my dearest friend Shala Nicely talking about how she manages mental compulsions.  In this episode, Shala shares her lived experience with Obsessive Compulsive Disorder and how she overcomes mental rituals.

In This Episode:

  • How to reduce mental compulsions for OCD and GAD.
  • How to use Flooding Techniques with Mental Compulsions
  • Magical Thinking and Mental Compulsions
  • BDD and Mental Compulsions

Links To Things I Talk About:

Shalanicely.com
Book: Is Fred in the Refridgerator?
Book: Everyday Mindfulness for OCD
ERP School: https://www.cbtschool.com/erp-school-lp

Episode Sponsor:

This episode of Your Anxiety Toolkit is brought to you by CBTschool.com.  CBTschool.com is a psychoeducation platform that provides courses and other online resources for people with anxiety, OCD, and Body-Focused Repetitive Behaviors.  Go to cbtschool.com to learn more.

Spread the love! Everyone needs tools for anxiety...

If you like Your Anxiety Toolkit Podcast, visit YOUR ANXIETY TOOLKIT PODCAST to subscribe free and you'll never miss an episode. And if you really like Your Anxiety Toolkit, I'd appreciate you telling a friend (maybe even two).

EPISODE TRANSCRIPTION

This is Your Anxiety Toolkit - Episode 284.

Welcome back, everybody. We are on the third video or the third part of this six-part series on how to manage mental compulsions. Last week’s episode with Jon Hershfield was bomb, like so good. And I will say that we, this week, have Shala Nicely, and she goes for it as well. So, I am so honored to have these amazing experts talking about mental compulsions, talking about what specific tools they use. 

So, I’m not going to take too much time of the intro this time, because I know you just want to get to the content. Again, I just want to put a disclaimer. This should not replace professional mental health care. This series is for educational purposes only. My job at CBT School is to give you as much education as I can, knowing that you may or may not have access to care or treatment in your own home. So, I’m hoping that this fills in a gap that maybe we’ve missed in the past in terms of we have ERP School, that’s an online course teaching you everything about ERP to get you started if you’re doing that on your own. But this is a bigger topic. This is an area that I’d need to make a complete new course. But instead of making a course, I’m bringing these experts to you for free, hopefully giving you the tools that you need. 

If you’re wanting additional information about ERP School, please go to CBTSchool.com. With that being said, let’s go straight over to this episode with Shala Nicely. 

Managing Mental Compulsions (With Shala Nicely) Your anxiety toolkit

Kimberley: Welcome, Shala. I am so happy to have you here.

Shala: I am so happy to be here. Thank you for having me.

Kimberley: Okay. So, I have heard a little bit of your views on this, but I am actually so excited now to get into the juicy details of how you address mental compulsions or mental rituals. First, I want to check in with you, do you call them mental compulsions, rituals, rumination? How do you address them?

Shala: Yeah. All those things. I also sometimes call it mental gymnastics up in your head, it’s all sorts of things you’re doing in your head to try to get some relief from anxiety.

Kimberley: Right. So, if you had a patient or a client who really was struggling with mental compulsions, whether or not they were doing other compulsions as well, how might you address that particular part of their symptomology?

Shala: So, let me answer that by stepping back a little bit and telling you about my own experience with this, because a lot of the way I do it is based on what I learned, trying to manage my own mental rituals. I’ve had OCD probably since I was five or six, untreated until I was 39. Stumbled upon the right treatment when I went to the IOCDF Conference and started doing exposure mostly on my own. I went to Reid Wilson’s two-day group, where I learned how to do it. But the rest of the time, I was implementing on my own. And even though I had quite a few physical compulsions, I would’ve considered myself a primary mental ritualizer, meaning if we look at the majority, my compulsions were up in my head. And the way I think about this is I think that sometimes if you have OCD for long enough, and you’ve got to go out and keep functioning in the world and you can’t do all these rituals so that people could see, because then people will be like, “What’s wrong with you? What are you doing?” you take them inward. And some mental compulsions can take the place of physical compulsions that you’re not able to do for whatever reason because you’re trying to function. And I’d had untreated OCD for so long that most of my rituals were up in my head, not all, but the great majority of them. 

 

Exposure & Response Prevention for Mental Compulsions

So, when I started to do exposure, what I found was I could do exposure therapy, straight up going and facing my fears, like going and being around things that might be triggering all I wanted, but I wasn’t necessarily getting better because I wasn’t addressing the mental rituals. So, basically, I’m doing exposure without response prevention or exposure with partial response prevention, which can make things either worse or just neutralize your efforts. So, what I did was I figured out how to be in the presence of triggers and not be up in my head, trying to do analyzing, justifying, figuring it out, replaying the situation with a different ending, all the sorts of things that I would do over and over in my head. And the way I did this was I took something I learned from Jonathan Grayson and his book, Freedom From OCD. I know you’re having him on for this series too. And he talked about doing all this ERP scripting, where you basically write out the worst-case scenario, what you think your OCD thinks is going to happen and you write it in either a worst-case way or an uncertainty-focused way. And what I did was after reading his book, I took that concept and I just shortened it down, and anything that my OCD was afraid of, I would just wrap may or may not surround it. 

So, for instance, an example that I use in Is Fred in the Refrigerator?, my memoir, Taming OCD and Reclaiming My Life was that I used to-- when I was walking through stores like Target, if I saw one of those little plastic price tags that had fallen on the ground, if I didn’t pick it up and put it out of harm’s way, I was afraid somebody was going to slip and fall and break their neck. And it would be on some security camera that I just walked on past it and didn’t do anything. So, a typical scrupulosity obsession. And so, going shopping was really hard because I’m cleaning up the store as I’m shopping. And so, what I would do is I would either go to Target, walk past the price tag. And then as I’m just passing the price tag, I would say things. And in Target, I obviously couldn’t do this really out loud, mumble it out loud as best, but I may or may not cause somebody to kill themselves by they’re going to slip and fall on that price tag because I didn’t pick it up. I may or may not be an awful, terrible rotten human being. They may or may not catch me and throw me into jail. I may or may not rot in prison. People may or may not find out what a really bad person I really am. This may or may not be OCD, et cetera, et cetera, et cetera. 

And that would allow me to be present with the obsessions, all the what-ifs – those are basically what-ifs turned into ‘may or may nots’ – without compulsing with them, without doing anything that would artificially lower my anxiety. So, it allowed me to be in the presence of those obsessive thoughts while interrupting the pattern of the mental rituals. And that’s really how I use ‘may or may nots’ and how I teach my clients to use ‘may or may nots’ today is using them to really be mindfully present of what the OCD is worried about while not interacting with that content in a way that’s going to make things worse. So, that’s how I developed it for myself. And I think that-- and that is a tool that I would say is an intermediary tool. So, I use that now in my own recovery. I don’t have to use ’may or may nots’. It’s very often at all. If I get super triggered, which doesn’t happen too terribly often, but if I get super triggered and I cannot get out of my head, I’ll use ’may or may nots’. 

But I think the continuum is that you try to do something to interrupt the mental rituals, which for me is the ’may or may nots’. You can also-- people can write down the scripts, they can do a worst-case scenario. But eventually, what you’re trying to get to is you’re trying to be able to hear the OCD, what-ifs in your head and completely ignore it. And I call that my shoulders back, the way of thinking about things. Just put your shoulders back and you move on with your day. You don’t acknowledge it. 

What I’ll do with clients, I’ll say, “If you had the thought of Blue Martian is going to land on my head, I mean, you wouldn’t even do anything with that thought. That thought would just go in and go out and wouldn’t get any of your attention.” That’s the way we want to treat OCD, is just thoughts can be there. I’m not going to say, “Oh, that’s my OCD.” I’m not going to say, “OCD, I’m not talking to you.” I’m not going to acknowledge it at all. I’m just going to treat it like any other weird thought that we have during the day and move on. 

Your question was, how would you help somebody who comes in with mental rituals? Well, first, I want to understand where are they in their OCD recovery? How long have they been doing these mental rituals? What percentage of their compulsions are mental versus physical? What are the kind of things that their OCD is afraid of? Basically, make a list or a hierarchy of everything they’re afraid of. And then we start working on exposure therapy. And when I have them do exposures, the first exposure I do with people, we’ll find something that’s-- I start in the middle of the hierarchy. You don’t have to, but I try. And I will have them face the fear. But then I’ll immediately ask them, what is your OCD saying right now? And they’ll tell me, and I’ll say, “I want you to repeat after me.” I have them do this, and everyone that I see hates this, but I have them do it. Standing up with their shoulders back like Wonder Woman, because this type of power pose helps them. It changes the chemistry of your body and helps you feel more powerful. 

OCD thinks it’s very powerful. So, I want my clients to feel as powerful as they can. So, I have them stand like Wonder Woman and they repeat after me. Somebody could-- let’s just say we are standing near something red on the floor. And I’ll say, “Well, what is your OCD saying right now?” And they’ll say, “Well, that’s blood and it could have AIDS in it, and I’m going to get sick.” I’ll say, “Well, that may or may not be a spot of blood on the floor. I may or may not get sick and I may or may not get AIDS, but I want to do this. I’m going to stay here. OCD, I want to be anxious, so bring it on.” 

And that’s how we do the exposure, is I ask them what’s in their head. I have them repeat it to me until they understand what the process is. And then I’m having them be in the presence of this and just script, script, script away. That’s what I call it scripting, so that they are in the presence of whatever’s bothering them, but they’re not up in their head. And anytime something comes in their head, I teach them to pull it down into the script. Never let something be circulating in your head without saying it out loud and pulling it into the script. 

I will work on this technique with clients as we’re working on exposures, because eventually what we’ll want to do is instead of going all over the place, “That may or may not be blood, I may or may not get AIDS, I may or may not get sick,” I’ll say, “Okay, of all the things you’ve just said, what does your OCD-- what is your OCD scared of the most? Let’s focus on that.” And so, “I may or may not get AIDS. I may or may not get AIDS. I may or may not have HIV. I may or may not get AIDS,” over again until people start to say, “Oh, okay. I guess I don’t have any control over this,” because what we’re trying to do is help the OCD habituate to the uncertainty. Habituate, I know that’d be a confusing word. You don’t have to habituate in order for exposure to work due to the theory of inhibitory learning, but we’re trying to help your brain get used to the uncertainty here.

Kimberley: And break into a different cycle instead of doing the old rumination cycle. 

Shala: Yes. And so then, I’ll teach people to just find their scariest fear. They say that over and over and over again. Then let’s hit the next one. “Well, my family may or may not survive if I die because if I get a fatal disease and I die and my family may or may not be left destitute,” and then over and over. “My family may or may not be left destitute. My family may or may not be left destitute, whatever,” until we’re hitting all the things that could be circulating in your head. 

Now, some people really don’t need to do that scripting because they’re not up in their head that much. But that’s the minority of people. I think most people with OCD are doing something in their head. And a lot of people aren’t aware of what they’re doing because these mental rituals are incredibly subtle at times. And so, as people, as my clients go out and work on these exposures, I’ll have them tell me how it’s going. I have people fill out forms on my website each day as they’re doing exposures so I can see what’s going on. And if they’re not really up in their head and they don’t really need to do the ‘may or may nots’, great. That’s better. In fact, just go do the exposure and go on with your life. If they’re up in their head, then I have them do the ’may or may nots’. And so, that’s how I would start with somebody. 

And so, what I’m trying to do is I’m giving them what I call a bridge tool. Because people who have been mental ritualizing for a long time, I have found it’s virtually impossible to just stop because that’s what your mind is used to doing. And so, what I’m doing is I’m giving them a competing response. And I’m saying here, instead of mental ritualizing, I’d like you to say a bunch of ’may or may nots’ statements while standing up and say them out loud while looking like Wonder Woman. Everybody rolls their eyes like, “Really?” But that’s what we do as a bridge tool. And so, they’ve lifted enough mental weights, so to speak, with this technique that they can hear the OCD and start to disengage and not interact with it at all. Then we move to that technique.

Flooding Techniques for Mental Rumination

Kimberley: Is there a reason why-- and for some of the listeners, they may have learned this before, but is there a reason why you use ’may or may nots’ instead of worst-case scenarios?

Shala: For me, for my personal OCD recovery journey, what I found with worst-case scenario is I got too lost in the content. I remember doing-- I had had a mammogram, it had come back with some abnormal findings. I spent the whole weekend trying to do scripting about what could happen, and I was using worst-case scenario. Well, I end up in the hospital, I end up with breast cancer, I end up dead. And by the end of the weekend, I was completely demoralized. And I’m like, “Well, I don’t bother because I’m going to be dead, because I have breast cancer.” That’s where my mind took it because I’ve had OCD long enough that if I get a really scary and I start and I play around in the content, I’m going to start losing insight and I’m going to start doing depression as a compulsion, which is the blog we did talk about, where you start acting depressed because you’re believing what the OCD says like, “Oh, well, I might as well just give up, I have breast cancer,” and then becoming depressed, and then acting like it’s true. And then that’s reinforcing the whole cycle. 

So, for me, worst-case scenario scripting made things worse. So, when I stayed in the uncertainty realm, the ‘may or may nots’ that helped because I was trying to help my brain understand, “Well, I may or may not have breast cancer. And if I do, I mean, I’ll go to the doctor, I’ll do what I need to do, but there’s nothing I can do about it right now in my head other than what I’m doing.”

Some people like worst-case scenario and it works fine for them. And I think that works too. I mostly use ’may or may nots’ with clients unless they are unable through numbing that they might be doing. If they’re unable to actually feel what they’re saying, because they’re used to turning it over in their head and pulling the anxiety down officially, and so I can’t get a rise out of the OCD because there’s a lot of really little subtle mental compulsions going on, then I’ll insert some worst-case scenario to get the anxiety level up, to help them really feel the fear, and then pull back into ’may or may nots’. But there’s nothing wrong with worst-case scenario. But for me, that was what happened. And I think if you are prone to depression, if you’re prone to losing insight into your OCD when you’ve got a really big one, I think that’s a risk factor for using that particular type of scripting. 

Magical Thinking and Mental Compulsions 

Kimberley: Right. And I found that they may or may not have worked just as well, except the one thing, and I’m actually curious on your opinion on this and I have not had this conversation, is I find that people who have a lot of magical thinking benefit by worst-case scenario, like their jinxing compulsions and so forth, like the fear of saying it means it will happen. So, saying the worst-case is the best exposure. Is that true for you?

Shala: I have not had to use it much on my own magically. I certainly had a lot of magical thinking. Like, if I don’t hit this green light, then somebody’s going to die. But I think the worst-case scenario, I could actually work well in that, because if you use the worst-case scenario, it can make it seem so ridiculous that it helps people let go of it more easily. And I think you can do that with ’may or may nots’ too. I’ll try to encourage people to use the creativity that they have because everybody with OCD has a ton of creativity. And we know that because the OCD shares your brain and it’s certainly the creative stuff

And to one-up the OCD, you use the scripting to be like, “Gosh, I may or may not get some drug-disease and give it to my entire neighborhood. I may or may not kill off an entire section of my county. We may or may not infect the entire state of Georgia. The entire United States may or may not blow up because I got this one disease. So, they may or may not have to eject me off the earth and make me live on Mars because I’m such a bad person.” This ‘may or may not’ is in all this crazy stuff too, because that’s how to win, is to one up the OCD. It thinks that’s scary, let’s go even scarier. But the scary you get, it also gets a little bit ridiculous after a while. And then the whole thing seems to be a little bit ridiculous. So, I think you can still use that worst-case stuff with may or may not.

Kimberley: Right. Okay. So, I mean, I will always sort of-- I know you really well. I’ve always held you so high in my mind in just how resilient and strong you are in doing this. How might you, or how do you help people who feel completely powerless at even addressing this? For you to say it, it sounds very like you’re just doing it and it’s so powerful. But for those who are really struggling with this idea of like, you said, coming out of your head, can you speak to how you address that in session if someone’s really struggling to engage in ’may or may nots’ and so forth?

Shala: Yeah. Well, thank you for the kind words, first off. I think that it’s really common for people with OCD by the time they get to a therapist to feel completely demoralized, especially if they’ve been to multiple therapists before they get to somebody who does ERP. And so, they feel like they’re the victim at the hands of a very cruel abuser that they can’t get away from. And so, they feel beaten down and they don’t know how to get out of their heads. They feel like they’re trapped in this mental prison. They can’t get out. And if somebody is struggling like that, and they’re doing the ’may or may nots’ and the OCD is reacting, which of course, it will, and coming back at them stronger, which I always warn people, this is going to happen. When you start poking at this, the OCD is going to poke back and poke back even harder, because it wants to get you back in line so it can keep you prisoner. 

So, what I’ll often do in those situations, if I see somebody is really feeling like they have been so victimized, that they’re never going to be able to get over this, is the type of script I have them do is more of an empowerment script, which could sound like this: “OCD, I’m not listening to you anymore. I’m not doing what you want. I am strong. I can do this.” And I might add some ’may or may nots’ in there. “And I want to be anxious. Come on, bring it on. You think that’s scary? Give me something else.” 

I know you’re having Reid Wilson on as part of this too. I learned all that “bring it on” type stuff and pushing for the anxiety from him. And I think helping people say that out loud can be really transformative. I’ve seen people just completely break down in tears of sort of, “Oh my gosh, I could do this,” like tears of empowerment from standing up and yelling at their OCD. 

If people like swearing, I also just have them swear at it, like they would really swear at somebody who had been abusing them if they had a chance, because swearing actually can make you feel more powerful too, and I want to use all the tools we can. So, I think scripting comes in a number of forms. It’s all about really taking what’s in your head, turning it into a helpful self-talk and saying it out loud. And the reason out loud is important for any type of scripting is that if you’re saying it in your head, it’s going to get mixed up with all the jumble of mental ruminating that’s going on. And saying it out loud makes it hard for you to ruminate. It’s not impossible, but it’s hard because you’re saying it. Your brain really is only processing one thing at a time. And so, if you’re talking and really paying attention to what you’re saying, it’s much harder to be up in your head spinning this around. 

And so, adding these empowerment scripts in with the ’may or may nots’ helps people both accept the uncertainty and feel like they can do this, feel like they can stand up to the OCD and say, “You’ve beaten me enough. No more. This is my life. I’m not letting you ruin it anymore. I am taking this back. I don’t care how long it takes. I don’t care what I have to do. I’m going to do this.” And that builds people up enough where they can feel like they can start approaching these exposures.

Kimberley: I love that. I think that is such-- I’ve had that same experience of how powerful empowerment can be in switching that behavior. It’s so important. Now, one thing I really want to ask you is, do you switch this method when you’re dealing with other anxiety disorders – health anxiety, social anxiety, panic disorder? What is your approach? Is there a difference or would you say the tools are the same?

Shala: There’s a slight difference between disorders. I think health anxiety, I treat exactly like OCD. Even some of the examples I gave here were really health anxiety statements. With panic disorder-- and again, I learned this from Reid and you can ask him more about this when you interview him. But with pain disorder, it’s all about, I want to feel more shorter breath, more like their elephant standing on my chest. I want my heart to be faster. But I’m doing this while I’m having people do exercises that would actually create those feelings, like breathing through a little bit of cocktail straw, jogging, turning up a space heater, and blowing it on themselves. So, we’re trying to create those symptoms and then talk out loud and say, “Come on, I want more of this. I want to feel more anxious. Give me the worst panic attack you’ve ever had.” So, it’s all about amping up the symptoms. 

With social anxiety, it’s a little bit different because with social anxiety, I would work on the cognitions first. Whereas with OCD, we don’t work on the cognitions at all, other than I want you to have a different cognitive relationship with your disorder and your anxiety. I want you to want the anxiety. I want you to want the OCD to come and bother you because that gives you an opportunity to practice. That’s the cognitive work with OCD. I do not work on the cognitive work on the content. I’m not going to say to somebody, “Well, the chance you’re going to get AIDS from that little spot of blood is very small.” That’s not going to be helpful 

With social anxiety, we’re actually working on those distorted cognitions at the beginning. And so, a lot of the work with social anxiety is going to be going out and testing those new cognitions, which really turns the exposures into what we call behavioral experiments. It’s more of a cognitive method. We’re going out and saying, “Gosh, my new belief, instead of everybody’s judging me, is, well, everybody is probably thinking about themselves and I’m going to go do some things that my social anxiety wouldn’t want me to do and test out that new belief.” I might have them use that new belief, but also if their anxiety gets really high and they’re having a hard time saying, “Well, that person may or may not be judging me. They may or may not be looking at me funny. They may or may not go home and tell people about me.” But really, we’re trying to do something a little bit different with social anxiety.

Kimberley: And what about with generalized anxiety? With the mental, a lot of rumination there, do you have a little shift in how you respond?

Shala: Yeah. So, it’s funny that the talk that Michelle Massi and others gave at IOCDF-- I think it was at IOCDF this year about what’s the difference between OCD and GAD is they’re really aligned there. I mean, I treat GAD very similarly the way I treat OCD in that people are up in their heads trying to do things. They’re also doing other types of safety behaviors, compulsive safety behaviors, but a lot of people GAD are just up in their head. They’re just worried about more “real-life” things. But again, a lot of OCD stuff can be real-life things. I mean, look at COVID. That was real life. And people’s OCD could wrap itself around that. So, I treat GAD and OCD quite similarly. There are some differences, but in terms of scripting, we call it “worry time” in GAD. It’s got a different name, but it’s basically the same thing.

Kimberley: Right. Okay. Thank you for answering that because I know some folks here listening will be not having OCD and will be curious to see how it affects them. So, is that the practice for you or is there anything else you feel like people need to know going in, in terms of like, “Here is my strategy, here is my plan to target mental rituals”? What would you say?

Shala: So, as I mentioned, I think the ’may or may nots’ are bridge tool that are always available to you throughout your entire recovery. My goal with anybody that I’m working with is to help them get to the point where they can just use shoulders back. And the way that I think about this is what I call my “man in the park” metaphor. So, we’ve all probably been in a park where somebody is yelling typically about the end of the world and all that stuff. And even if you were to agree with some of the things that the person might say from a spiritual or religious standpoint, you don’t run home and go, “Oh my gosh, we got to pack all our things up because it’s the end of the world. We have to get with all of our relatives and be together because we’re all going to die.” We don’t do that. We hear what this guy’s saying, and then we go on with our days, again, even if you might agree with some of the content.

Now, why do we do that? We do that because it’s not relevant in our life. We realize that person probably, unfortunately, has some problems. But it doesn’t affect us. We hear it just like when we might hear birds in the background or a car honking, and we just go on with our day. That’s how we want to treat OCD. What we do when we have untreated OCD is we run up to the man in the park and we say, “Oh my gosh, can I have a pamphlet? Let me read the pamphlet. Oh my gosh, you’re right. Tell me more, tell me more.” And we’re interacting with him, trying to get some reassurance that maybe he’s wrong, that maybe he does really mean the end of the world is coming soon. Maybe it’s going to be like in a hundred years. Eventually, we get to the point where we’re handing out pamphlets for him. “Here, everybody, take one of these.”

What we’re doing with ’may or may nots’ is we’re learning how to walk by the man in the park and go, “The world may or may not be ending. The world may or may not be ending. I’m not taking a pamphlet. The world may or may not be ending.” So, we’re trying to not interact with him. We’re trying to take what he’s saying and hold it in our heads without doing something compulsive that’s going to make our anxiety higher. What we’re trying to do is practice that enough till we can get to the point where we can be in the park with the guy and just go on with our day. We hear him speaking, but we’re really-- it’s just not relevant. It’s just not part of our life. So, we just move on. And we’re not trying to shove him away. It’s just like any other noise or sound or activity that you would just-- it doesn’t even register in your consciousness. That’s what we’re trying to do. 

Now I think another way to think about this is if you think-- say you’re in an art gallery. Art galleries are quiet and there are lots of people standing around, and there’s somebody in there that you don’t like or who doesn’t like you or whatever. You’re not going to walk up to that person and tap on their shoulder and say, “Excuse me, I’m going to ignore you.” You’re just going to be like, “I know that person is there. I’m just going to do what I’m doing.” And I think that’s-- I use that to help people understand this transition, because we’re basically going from ’may or may nots’ where we’re saying, “OCD, I’m not letting you do this to me anymore,” so we are being really aggressive with it, to this being able to be in the same space with it, but we’re not talking to it at all because we don’t need to, because we can be in the presence with the intrusive thoughts that the OCD is reacting to, just like the presence of all the other thousands of thoughts we have each day without interacting with them.

Kimberley: That’s so interesting. I’ve never thought of it that way. 

Shala: And so, that’s where I’m trying to get people because that is the strongest, strongest recovery, is if you can go do the things that you want to do, be in the presence of the anxiety and not do compulsions physical or mental, you don’t give anything for OCD to work with. I have a whole chapter in my memoir about this after I heard Reid say at one of the conferences, “We need to act as though what OCD is saying doesn’t matter.” And that was revolutionary to me to hear that. And that’s what we’re trying to do both physically and mentally. Because if you can have an obsession and focus on what you want to focus on, do what you want to do, you’re not giving OCD anything to work with. And typically, it’ll just drain away. But this takes time. I mean, it has taken me years to learn how to do this, but I went untreated for 35 years too. It may not take you years, but it may. And that’s okay. It’s a process. And I think if you have trouble trying to do shoulders back, man in the park, use ’may or may nots’. You can use the combination. But I think we’re trying to get to the point where you can just be with the OCD and hear it flipping out and just go on with your day.

OCD, BDD, and Mental Rituals 

Kimberley: In your book, you talk about the different voices. There is a BDD voice and an OCD voice. Was it harder or easier depending on the voice? Was that a component for you in that-- because the words and the voice sound a little different. I know in your memoir you give them different names and so forth, which if anyone hasn’t read your memoir, they need to go right now and read it. Do you have any thoughts on that in terms of the different voices or the different ways in which the disorders interact?

Shala: That’s a really great question because yes, I think OCD does shift its voice and shift its persona based on how scared it is. So, if it’s a little bit scared, it’s probably going to speak to you. It’s still going to be not a very nice voice. It might be urgent and pleading. But if it’s super scared, I talk about mine being like the triad of hell, how my OCD will personify into different things based on how scared it is. And if it’s super scared and it’s going to get super big and it’s going to get super loud in your head because it’s trying desperately to help you understand you’ve got to save it because it thinks it’s in danger. That’s all its content. Then I think-- and if you have trouble ignoring it because it’s screaming in your head, like the man in the park comes over with his megaphone, puts it right up against your ear and starts talking, that’s hard to ignore. That’s hard to act like that’s not relevant because it hurts. There’s so much noise. 

That’s when you might have to use a may or may not type approach because it’s just so loud, you can’t ignore it, because it’s so scared. And that’s okay. And again, sometimes I’ll have to use that. Not too terribly often just because I’ve spent a long time working on how to use the shoulder’s back, man in the park, but if I have to use it, I use it. And so, I think your thought about how do I interact with the OCD based on how aggressive it’s being also plays into this.

Kimberley: I love all this. I think this is really helpful in terms of being able to be flexible. I know sometimes we want just the one rule that’s going to work in all situations, but I think you’re right. I think that there needs to be different approaches. And would you say it depends on the person? Do you give them some autonomy over finding what works for them, or what would you say? 

Shala: Absolutely. If people are up in their heads and they don’t want to use ’may or may nots’, I’ll try to use some other things. If I really, really think that that’s what we need right now, is we need scripting, I’ll try to sell them on why. But at the end of the day, it’s always my client’s choice and I do it differently based on every client. For some clients, it might be just more empowering statements. For some clients where it’s more panicky focused, it might be more about bringing on your anxiety. Sometimes it might be pulling self-compassion in and just saying the self-compassion statements out loud. So, it really does vary by person. There’s no one-size-fits-all, but I think, I feel that people need to have something to replace the mental ritualizing with at the beginning that they’ve been doing it for a long time, just because otherwise, it’s like, I’m giving them a bicycle, they’ve never ridden a bicycle before and I won’t give them any training wheels. And that’s really, really hard. Some people can do it. I mean, some people can just be like, “Oh, I’m to stop doing that in my head? Okay, well, I’ll stop doing that in my head.” But most people need something to help them bridge that gap to get to the point where they can just be in the presence with it and not be talking to it in their heads.

Kimberley: Amazing. All right. Any final statements from you as we get close to the end?

Shala: I think that it’s important to, as you’re working on this, really think about what you’re doing in your head that might be subtle, that could be making the OCD worse. And I think talking and being willing to talk about this to therapists about putting it all out there, “Hey, I’m saying this to myself in my head, is that helpful or harmful?” Because OCD therapy can be pretty straightforward. I mean, ERP, go out and face your fears, don’t do rituals. It sounds pretty straightforward. But there is a lot of subtlety to this. And the more that you can root out these subtle mental rituals, the better that your recovery is going to be. 

And know too that if you’ve had untreated OCD for a long time, you can uncover mental rituals, little bitty ones, for years after you get out of therapy. And that’s okay. It doesn’t mean you’re not in recovery. It just means that you are getting more and more insightful and educated about what OCD is. And the more that you can pick those little things out, just the better your recovery will be. But we also don’t want to be perfectionistic about that like, “I must eliminate every single mental ritual that I have or I’m not going to be in a good recovery.” That’s approaching your ERP like OCD would do. And we don’t want to do that. But we do want to be mindful about the subtleties and make sure to try to pull out as many of those subtle things that we might be doing in our heads as possible. 

Kimberley: Amazing. Thank you. Tell us-- again, first, let me just say, such helpful information. And your personal experience, I think, is really validating and helpful to hear on those little nuances. Tell us where people can hear about you and the amazing projects you’ve got going on.

Shala: You can go to ShalaNicely.com and I have lots of free blog posts I’ve written on this. So, there are two blog posts, two pretty extensive blog posts on ’may or may nots’. So, if you go on my website and just search may or may not, it’ll bring up two blog posts about that. If you search on shoulders back or man in the park, you’ll find two blog posts on how to do that technique. I also have a blog post I wrote in the last year or so called Shower Scripting, which is how to do ERP, like just some touch-up scripting in the shower, use that time. So, I would say go to my website and you can find all sorts of free resources. I’ve got two books. You can find on Amazon, Everyday Mindfulness for OCD, Jon Hershfield and I co-wrote. And we talk about ‘may or may nots’ and shoulders back and some of the things in there just briefly. And then my memoir, Is Fred in the Refrigerator?: Taming OCD and Reclaiming My Life, is also on Amazon or bookstores, Audible, and that kind of thing. 

Kimberley: I wonder too, if we could-- I’m going to put links to all these in the show note. I remember you having a word with your OCD, a video?

Shala: Oh yes, that’s true.

Kimberley: Can we link that too?

Shala: Yes. And that one I have under my COVID resources, because I’m so glad you brought that up. When the pandemic started, my OCD did not like it, as many people who have contamination OCD can relate to. And it was pretty scary all the time. And it was making me scared all the time. And eventually, I just wrote it a letter and I’m like, “Dude, we’re not doing this anymore.” And I read it out loud and I recorded it out loud so that people could hear how I was talking to it. 

Kimberley: It was so powerful.

Shala: Well, thank you. And it’s fun to do. I think the more that you can personify your OCD, the more you can think of it as an entity that is within you but is not you, and to recognize that your relationship with it will change over time. Sometimes you’re going to be compassionate with it. “Gosh, OCD, I’m so sorry,” You’re scared we’re doing this anyway. Sometimes you’re going to be aggressive with it. Sometimes you just ignore it. And that changes as you go through therapy, it changes through your life. And I think that recognizing that it’s okay to have OCD and to have this little thing, I think of like an orange ball with big feet and sunglasses is how I think about it when it’s behaving – it makes it less of an adversarial relationship over time and more like I have an annoying little sibling that, gosh, it’s just not going to ever not be there, but it’s fine. We can live together and live in this uncertainty and be happy anyway.

Kimberley: I just love it. Thank you so much for being here and sharing your experience and your knowledge. It’s so wonderful.

Shala: Thank you so much for having me.

May 13, 2022

SUMMARY: 

In this weeks podcast, we have my dearest friend Shala Nicely talking about how she manages mental compulsions.  In this episode, Shala shares her lived experience with Obsessive Compulsive Disorder and how she overcomes mental rituals.

In This Episode:

  • How to reduce mental compulsions for OCD and GAD.
  • How to use Flooding Techniques with Mental Compulsions
  • Magical Thinking and Mental Compulsions
  • BDD and Mental Compulsions

Links To Things I Talk About:

Shalanicely.com
Book: Is Fred in the Refridgerator?
Book: Everyday Mindfulness for OCD
ERP School: https://www.cbtschool.com/erp-school-lp

Episode Sponsor:

This episode of Your Anxiety Toolkit is brought to you by CBTschool.com.  CBTschool.com is a psychoeducation platform that provides courses and other online resources for people with anxiety, OCD, and Body-Focused Repetitive Behaviors.  Go to cbtschool.com to learn more.

Spread the love! Everyone needs tools for anxiety...

If you like Your Anxiety Toolkit Podcast, visit YOUR ANXIETY TOOLKIT PODCAST to subscribe free and you'll never miss an episode. And if you really like Your Anxiety Toolkit, I'd appreciate you telling a friend (maybe even two).

EPISODE TRANSCRIPTION

This is Your Anxiety Toolkit - Episode 284.

Welcome back, everybody. We are on the third video or the third part of this six-part series on how to manage mental compulsions. Last week’s episode with Jon Hershfield was bomb, like so good. And I will say that we, this week, have Shala Nicely, and she goes for it as well. So, I am so honored to have these amazing experts talking about mental compulsions, talking about what specific tools they use. 

So, I’m not going to take too much time of the intro this time, because I know you just want to get to the content. Again, I just want to put a disclaimer. This should not replace professional mental health care. This series is for educational purposes only. My job at CBT School is to give you as much education as I can, knowing that you may or may not have access to care or treatment in your own home. So, I’m hoping that this fills in a gap that maybe we’ve missed in the past in terms of we have ERP School, that’s an online course teaching you everything about ERP to get you started if you’re doing that on your own. But this is a bigger topic. This is an area that I’d need to make a complete new course. But instead of making a course, I’m bringing these experts to you for free, hopefully giving you the tools that you need. 

If you’re wanting additional information about ERP School, please go to CBTSchool.com. With that being said, let’s go straight over to this episode with Shala Nicely. 

Managing Mental Compulsions (With Shala Nicely) Your anxiety toolkit

Kimberley: Welcome, Shala. I am so happy to have you here.

Shala: I am so happy to be here. Thank you for having me.

Kimberley: Okay. So, I have heard a little bit of your views on this, but I am actually so excited now to get into the juicy details of how you address mental compulsions or mental rituals. First, I want to check in with you, do you call them mental compulsions, rituals, rumination? How do you address them?

Shala: Yeah. All those things. I also sometimes call it mental gymnastics up in your head, it’s all sorts of things you’re doing in your head to try to get some relief from anxiety.

Kimberley: Right. So, if you had a patient or a client who really was struggling with mental compulsions, whether or not they were doing other compulsions as well, how might you address that particular part of their symptomology?

Shala: So, let me answer that by stepping back a little bit and telling you about my own experience with this, because a lot of the way I do it is based on what I learned, trying to manage my own mental rituals. I’ve had OCD probably since I was five or six, untreated until I was 39. Stumbled upon the right treatment when I went to the IOCDF Conference and started doing exposure mostly on my own. I went to Reid Wilson’s two-day group, where I learned how to do it. But the rest of the time, I was implementing on my own. And even though I had quite a few physical compulsions, I would’ve considered myself a primary mental ritualizer, meaning if we look at the majority, my compulsions were up in my head. And the way I think about this is I think that sometimes if you have OCD for long enough, and you’ve got to go out and keep functioning in the world and you can’t do all these rituals so that people could see, because then people will be like, “What’s wrong with you? What are you doing?” you take them inward. And some mental compulsions can take the place of physical compulsions that you’re not able to do for whatever reason because you’re trying to function. And I’d had untreated OCD for so long that most of my rituals were up in my head, not all, but the great majority of them. 

Exposure & Response Prevention for Mental Compulsions

So, when I started to do exposure, what I found was I could do exposure therapy, straight up going and facing my fears, like going and being around things that might be triggering all I wanted, but I wasn’t necessarily getting better because I wasn’t addressing the mental rituals. So, basically, I’m doing exposure without response prevention or exposure with partial response prevention, which can make things either worse or just neutralize your efforts. So, what I did was I figured out how to be in the presence of triggers and not be up in my head, trying to do analyzing, justifying, figuring it out, replaying the situation with a different ending, all the sorts of things that I would do over and over in my head. And the way I did this was I took something I learned from Jonathan Grayson and his book, Freedom From OCD. I know you’re having him on for this series too. And he talked about doing all this ERP scripting, where you basically write out the worst-case scenario, what you think your OCD thinks is going to happen and you write it in either a worst-case way or an uncertainty-focused way. And what I did was after reading his book, I took that concept and I just shortened it down, and anything that my OCD was afraid of, I would just wrap may or may not surround it. 

So, for instance, an example that I use in Is Fred in the Refrigerator?, my memoir, Taming OCD and Reclaiming My Life was that I used to-- when I was walking through stores like Target, if I saw one of those little plastic price tags that had fallen on the ground, if I didn’t pick it up and put it out of harm’s way, I was afraid somebody was going to slip and fall and break their neck. And it would be on some security camera that I just walked on past it and didn’t do anything. So, a typical scrupulosity obsession. And so, going shopping was really hard because I’m cleaning up the store as I’m shopping. And so, what I would do is I would either go to Target, walk past the price tag. And then as I’m just passing the price tag, I would say things. And in Target, I obviously couldn’t do this really out loud, mumble it out loud as best, but I may or may not cause somebody to kill themselves by they’re going to slip and fall on that price tag because I didn’t pick it up. I may or may not be an awful, terrible rotten human being. They may or may not catch me and throw me into jail. I may or may not rot in prison. People may or may not find out what a really bad person I really am. This may or may not be OCD, et cetera, et cetera, et cetera. 

And that would allow me to be present with the obsessions, all the what-ifs – those are basically what-ifs turned into ‘may or may nots’ – without compulsing with them, without doing anything that would artificially lower my anxiety. So, it allowed me to be in the presence of those obsessive thoughts while interrupting the pattern of the mental rituals. And that’s really how I use ‘may or may nots’ and how I teach my clients to use ‘may or may nots’ today is using them to really be mindfully present of what the OCD is worried about while not interacting with that content in a way that’s going to make things worse. So, that’s how I developed it for myself. And I think that-- and that is a tool that I would say is an intermediary tool. So, I use that now in my own recovery. I don’t have to use ’may or may nots’. It’s very often at all. If I get super triggered, which doesn’t happen too terribly often, but if I get super triggered and I cannot get out of my head, I’ll use ’may or may nots’. 

But I think the continuum is that you try to do something to interrupt the mental rituals, which for me is the ’may or may nots’. You can also-- people can write down the scripts, they can do a worst-case scenario. But eventually, what you’re trying to get to is you’re trying to be able to hear the OCD, what-ifs in your head and completely ignore it. And I call that my shoulders back, the way of thinking about things. Just put your shoulders back and you move on with your day. You don’t acknowledge it. 

What I’ll do with clients, I’ll say, “If you had the thought of Blue Martian is going to land on my head, I mean, you wouldn’t even do anything with that thought. That thought would just go in and go out and wouldn’t get any of your attention.” That’s the way we want to treat OCD, is just thoughts can be there. I’m not going to say, “Oh, that’s my OCD.” I’m not going to say, “OCD, I’m not talking to you.” I’m not going to acknowledge it at all. I’m just going to treat it like any other weird thought that we have during the day and move on. 

Your question was, how would you help somebody who comes in with mental rituals? Well, first, I want to understand where are they in their OCD recovery? How long have they been doing these mental rituals? What percentage of their compulsions are mental versus physical? What are the kind of things that their OCD is afraid of? Basically, make a list or a hierarchy of everything they’re afraid of. And then we start working on exposure therapy. And when I have them do exposures, the first exposure I do with people, we’ll find something that’s-- I start in the middle of the hierarchy. You don’t have to, but I try. And I will have them face the fear. But then I’ll immediately ask them, what is your OCD saying right now? And they’ll tell me, and I’ll say, “I want you to repeat after me.” I have them do this, and everyone that I see hates this, but I have them do it. Standing up with their shoulders back like Wonder Woman, because this type of power pose helps them. It changes the chemistry of your body and helps you feel more powerful. 

OCD thinks it’s very powerful. So, I want my clients to feel as powerful as they can. So, I have them stand like Wonder Woman and they repeat after me. Somebody could-- let’s just say we are standing near something red on the floor. And I’ll say, “Well, what is your OCD saying right now?” And they’ll say, “Well, that’s blood and it could have AIDS in it, and I’m going to get sick.” I’ll say, “Well, that may or may not be a spot of blood on the floor. I may or may not get sick and I may or may not get AIDS, but I want to do this. I’m going to stay here. OCD, I want to be anxious, so bring it on.” 

And that’s how we do the exposure, is I ask them what’s in their head. I have them repeat it to me until they understand what the process is. And then I’m having them be in the presence of this and just script, script, script away. That’s what I call it scripting, so that they are in the presence of whatever’s bothering them, but they’re not up in their head. And anytime something comes in their head, I teach them to pull it down into the script. Never let something be circulating in your head without saying it out loud and pulling it into the script. 

I will work on this technique with clients as we’re working on exposures, because eventually what we’ll want to do is instead of going all over the place, “That may or may not be blood, I may or may not get AIDS, I may or may not get sick,” I’ll say, “Okay, of all the things you’ve just said, what does your OCD-- what is your OCD scared of the most? Let’s focus on that.” And so, “I may or may not get AIDS. I may or may not get AIDS. I may or may not have HIV. I may or may not get AIDS,” over again until people start to say, “Oh, okay. I guess I don’t have any control over this,” because what we’re trying to do is help the OCD habituate to the uncertainty. Habituate, I know that’d be a confusing word. You don’t have to habituate in order for exposure to work due to the theory of inhibitory learning, but we’re trying to help your brain get used to the uncertainty here.

Kimberley: And break into a different cycle instead of doing the old rumination cycle. 

Shala: Yes. And so then, I’ll teach people to just find their scariest fear. They say that over and over and over again. Then let’s hit the next one. “Well, my family may or may not survive if I die because if I get a fatal disease and I die and my family may or may not be left destitute,” and then over and over. “My family may or may not be left destitute. My family may or may not be left destitute, whatever,” until we’re hitting all the things that could be circulating in your head. 

Now, some people really don’t need to do that scripting because they’re not up in their head that much. But that’s the minority of people. I think most people with OCD are doing something in their head. And a lot of people aren’t aware of what they’re doing because these mental rituals are incredibly subtle at times. And so, as people, as my clients go out and work on these exposures, I’ll have them tell me how it’s going. I have people fill out forms on my website each day as they’re doing exposures so I can see what’s going on. And if they’re not really up in their head and they don’t really need to do the ‘may or may nots’, great. That’s better. In fact, just go do the exposure and go on with your life. If they’re up in their head, then I have them do the ’may or may nots’. And so, that’s how I would start with somebody. 

And so, what I’m trying to do is I’m giving them what I call a bridge tool. Because people who have been mental ritualizing for a long time, I have found it’s virtually impossible to just stop because that’s what your mind is used to doing. And so, what I’m doing is I’m giving them a competing response. And I’m saying here, instead of mental ritualizing, I’d like you to say a bunch of ’may or may nots’ statements while standing up and say them out loud while looking like Wonder Woman. Everybody rolls their eyes like, “Really?” But that’s what we do as a bridge tool. And so, they’ve lifted enough mental weights, so to speak, with this technique that they can hear the OCD and start to disengage and not interact with it at all. Then we move to that technique.

Flooding Techniques for Mental Rumination

Kimberley: Is there a reason why-- and for some of the listeners, they may have learned this before, but is there a reason why you use ’may or may nots’ instead of worst-case scenarios?

Shala: For me, for my personal OCD recovery journey, what I found with worst-case scenario is I got too lost in the content. I remember doing-- I had had a mammogram, it had come back with some abnormal findings. I spent the whole weekend trying to do scripting about what could happen, and I was using worst-case scenario. Well, I end up in the hospital, I end up with breast cancer, I end up dead. And by the end of the weekend, I was completely demoralized. And I’m like, “Well, I don’t bother because I’m going to be dead, because I have breast cancer.” That’s where my mind took it because I’ve had OCD long enough that if I get a really scary and I start and I play around in the content, I’m going to start losing insight and I’m going to start doing depression as a compulsion, which is the blog we did talk about, where you start acting depressed because you’re believing what the OCD says like, “Oh, well, I might as well just give up, I have breast cancer,” and then becoming depressed, and then acting like it’s true. And then that’s reinforcing the whole cycle. 

So, for me, worst-case scenario scripting made things worse. So, when I stayed in the uncertainty realm, the ‘may or may nots’ that helped because I was trying to help my brain understand, “Well, I may or may not have breast cancer. And if I do, I mean, I’ll go to the doctor, I’ll do what I need to do, but there’s nothing I can do about it right now in my head other than what I’m doing.”

Some people like worst-case scenario and it works fine for them. And I think that works too. I mostly use ’may or may nots’ with clients unless they are unable through numbing that they might be doing. If they’re unable to actually feel what they’re saying, because they’re used to turning it over in their head and pulling the anxiety down officially, and so I can’t get a rise out of the OCD because there’s a lot of really little subtle mental compulsions going on, then I’ll insert some worst-case scenario to get the anxiety level up, to help them really feel the fear, and then pull back into ’may or may nots’. But there’s nothing wrong with worst-case scenario. But for me, that was what happened. And I think if you are prone to depression, if you’re prone to losing insight into your OCD when you’ve got a really big one, I think that’s a risk factor for using that particular type of scripting. 

Magical Thinking and Mental Compulsions 

Kimberley: Right. And I found that they may or may not have worked just as well, except the one thing, and I’m actually curious on your opinion on this and I have not had this conversation, is I find that people who have a lot of magical thinking benefit by worst-case scenario, like their jinxing compulsions and so forth, like the fear of saying it means it will happen. So, saying the worst-case is the best exposure. Is that true for you?

Shala: I have not had to use it much on my own magically. I certainly had a lot of magical thinking. Like, if I don’t hit this green light, then somebody’s going to die. But I think the worst-case scenario, I could actually work well in that, because if you use the worst-case scenario, it can make it seem so ridiculous that it helps people let go of it more easily. And I think you can do that with ’may or may nots’ too. I’ll try to encourage people to use the creativity that they have because everybody with OCD has a ton of creativity. And we know that because the OCD shares your brain and it’s certainly the creative stuff

And to one-up the OCD, you use the scripting to be like, “Gosh, I may or may not get some drug-disease and give it to my entire neighborhood. I may or may not kill off an entire section of my county. We may or may not infect the entire state of Georgia. The entire United States may or may not blow up because I got this one disease. So, they may or may not have to eject me off the earth and make me live on Mars because I’m such a bad person.” This ‘may or may not’ is in all this crazy stuff too, because that’s how to win, is to one up the OCD. It thinks that’s scary, let’s go even scarier. But the scary you get, it also gets a little bit ridiculous after a while. And then the whole thing seems to be a little bit ridiculous. So, I think you can still use that worst-case stuff with may or may not.

Kimberley: Right. Okay. So, I mean, I will always sort of-- I know you really well. I’ve always held you so high in my mind in just how resilient and strong you are in doing this. How might you, or how do you help people who feel completely powerless at even addressing this? For you to say it, it sounds very like you’re just doing it and it’s so powerful. But for those who are really struggling with this idea of like, you said, coming out of your head, can you speak to how you address that in session if someone’s really struggling to engage in ’may or may nots’ and so forth?

Shala: Yeah. Well, thank you for the kind words, first off. I think that it’s really common for people with OCD by the time they get to a therapist to feel completely demoralized, especially if they’ve been to multiple therapists before they get to somebody who does ERP. And so, they feel like they’re the victim at the hands of a very cruel abuser that they can’t get away from. And so, they feel beaten down and they don’t know how to get out of their heads. They feel like they’re trapped in this mental prison. They can’t get out. And if somebody is struggling like that, and they’re doing the ’may or may nots’ and the OCD is reacting, which of course, it will, and coming back at them stronger, which I always warn people, this is going to happen. When you start poking at this, the OCD is going to poke back and poke back even harder, because it wants to get you back in line so it can keep you prisoner. 

So, what I’ll often do in those situations, if I see somebody is really feeling like they have been so victimized, that they’re never going to be able to get over this, is the type of script I have them do is more of an empowerment script, which could sound like this: “OCD, I’m not listening to you anymore. I’m not doing what you want. I am strong. I can do this.” And I might add some ’may or may nots’ in there. “And I want to be anxious. Come on, bring it on. You think that’s scary? Give me something else.” 

I know you’re having Reid Wilson on as part of this too. I learned all that “bring it on” type stuff and pushing for the anxiety from him. And I think helping people say that out loud can be really transformative. I’ve seen people just completely break down in tears of sort of, “Oh my gosh, I could do this,” like tears of empowerment from standing up and yelling at their OCD. 

If people like swearing, I also just have them swear at it, like they would really swear at somebody who had been abusing them if they had a chance, because swearing actually can make you feel more powerful too, and I want to use all the tools we can. So, I think scripting comes in a number of forms. It’s all about really taking what’s in your head, turning it into a helpful self-talk and saying it out loud. And the reason out loud is important for any type of scripting is that if you’re saying it in your head, it’s going to get mixed up with all the jumble of mental ruminating that’s going on. And saying it out loud makes it hard for you to ruminate. It’s not impossible, but it’s hard because you’re saying it. Your brain really is only processing one thing at a time. And so, if you’re talking and really paying attention to what you’re saying, it’s much harder to be up in your head spinning this around. 

And so, adding these empowerment scripts in with the ’may or may nots’ helps people both accept the uncertainty and feel like they can do this, feel like they can stand up to the OCD and say, “You’ve beaten me enough. No more. This is my life. I’m not letting you ruin it anymore. I am taking this back. I don’t care how long it takes. I don’t care what I have to do. I’m going to do this.” And that builds people up enough where they can feel like they can start approaching these exposures.

Kimberley: I love that. I think that is such-- I’ve had that same experience of how powerful empowerment can be in switching that behavior. It’s so important. Now, one thing I really want to ask you is, do you switch this method when you’re dealing with other anxiety disorders – health anxiety, social anxiety, panic disorder? What is your approach? Is there a difference or would you say the tools are the same?

Shala: There’s a slight difference between disorders. I think health anxiety, I treat exactly like OCD. Even some of the examples I gave here were really health anxiety statements. With panic disorder-- and again, I learned this from Reid and you can ask him more about this when you interview him. But with pain disorder, it’s all about, I want to feel more shorter breath, more like their elephant standing on my chest. I want my heart to be faster. But I’m doing this while I’m having people do exercises that would actually create those feelings, like breathing through a little bit of cocktail straw, jogging, turning up a space heater, and blowing it on themselves. So, we’re trying to create those symptoms and then talk out loud and say, “Come on, I want more of this. I want to feel more anxious. Give me the worst panic attack you’ve ever had.” So, it’s all about amping up the symptoms. 

With social anxiety, it’s a little bit different because with social anxiety, I would work on the cognitions first. Whereas with OCD, we don’t work on the cognitions at all, other than I want you to have a different cognitive relationship with your disorder and your anxiety. I want you to want the anxiety. I want you to want the OCD to come and bother you because that gives you an opportunity to practice. That’s the cognitive work with OCD. I do not work on the cognitive work on the content. I’m not going to say to somebody, “Well, the chance you’re going to get AIDS from that little spot of blood is very small.” That’s not going to be helpful 

With social anxiety, we’re actually working on those distorted cognitions at the beginning. And so, a lot of the work with social anxiety is going to be going out and testing those new cognitions, which really turns the exposures into what we call behavioral experiments. It’s more of a cognitive method. We’re going out and saying, “Gosh, my new belief, instead of everybody’s judging me, is, well, everybody is probably thinking about themselves and I’m going to go do some things that my social anxiety wouldn’t want me to do and test out that new belief.” I might have them use that new belief, but also if their anxiety gets really high and they’re having a hard time saying, “Well, that person may or may not be judging me. They may or may not be looking at me funny. They may or may not go home and tell people about me.” But really, we’re trying to do something a little bit different with social anxiety.

Kimberley: And what about with generalized anxiety? With the mental, a lot of rumination there, do you have a little shift in how you respond?

Shala: Yeah. So, it’s funny that the talk that Michelle Massi and others gave at IOCDF-- I think it was at IOCDF this year about what’s the difference between OCD and GAD is they’re really aligned there. I mean, I treat GAD very similarly the way I treat OCD in that people are up in their heads trying to do things. They’re also doing other types of safety behaviors, compulsive safety behaviors, but a lot of people GAD are just up in their head. They’re just worried about more “real-life” things. But again, a lot of OCD stuff can be real-life things. I mean, look at COVID. That was real life. And people’s OCD could wrap itself around that. So, I treat GAD and OCD quite similarly. There are some differences, but in terms of scripting, we call it “worry time” in GAD. It’s got a different name, but it’s basically the same thing.

Kimberley: Right. Okay. Thank you for answering that because I know some folks here listening will be not having OCD and will be curious to see how it affects them. So, is that the practice for you or is there anything else you feel like people need to know going in, in terms of like, “Here is my strategy, here is my plan to target mental rituals”? What would you say?

Shala: So, as I mentioned, I think the ’may or may nots’ are bridge tool that are always available to you throughout your entire recovery. My goal with anybody that I’m working with is to help them get to the point where they can just use shoulders back. And the way that I think about this is what I call my “man in the park” metaphor. So, we’ve all probably been in a park where somebody is yelling typically about the end of the world and all that stuff. And even if you were to agree with some of the things that the person might say from a spiritual or religious standpoint, you don’t run home and go, “Oh my gosh, we got to pack all our things up because it’s the end of the world. We have to get with all of our relatives and be together because we’re all going to die.” We don’t do that. We hear what this guy’s saying, and then we go on with our days, again, even if you might agree with some of the content.

Now, why do we do that? We do that because it’s not relevant in our life. We realize that person probably, unfortunately, has some problems. But it doesn’t affect us. We hear it just like when we might hear birds in the background or a car honking, and we just go on with our day. That’s how we want to treat OCD. What we do when we have untreated OCD is we run up to the man in the park and we say, “Oh my gosh, can I have a pamphlet? Let me read the pamphlet. Oh my gosh, you’re right. Tell me more, tell me more.” And we’re interacting with him, trying to get some reassurance that maybe he’s wrong, that maybe he does really mean the end of the world is coming soon. Maybe it’s going to be like in a hundred years. Eventually, we get to the point where we’re handing out pamphlets for him. “Here, everybody, take one of these.”

What we’re doing with ’may or may nots’ is we’re learning how to walk by the man in the park and go, “The world may or may not be ending. The world may or may not be ending. I’m not taking a pamphlet. The world may or may not be ending.” So, we’re trying to not interact with him. We’re trying to take what he’s saying and hold it in our heads without doing something compulsive that’s going to make our anxiety higher. What we’re trying to do is practice that enough till we can get to the point where we can be in the park with the guy and just go on with our day. We hear him speaking, but we’re really-- it’s just not relevant. It’s just not part of our life. So, we just move on. And we’re not trying to shove him away. It’s just like any other noise or sound or activity that you would just-- it doesn’t even register in your consciousness. That’s what we’re trying to do. 

Now I think another way to think about this is if you think-- say you’re in an art gallery. Art galleries are quiet and there are lots of people standing around, and there’s somebody in there that you don’t like or who doesn’t like you or whatever. You’re not going to walk up to that person and tap on their shoulder and say, “Excuse me, I’m going to ignore you.” You’re just going to be like, “I know that person is there. I’m just going to do what I’m doing.” And I think that’s-- I use that to help people understand this transition, because we’re basically going from ’may or may nots’ where we’re saying, “OCD, I’m not letting you do this to me anymore,” so we are being really aggressive with it, to this being able to be in the same space with it, but we’re not talking to it at all because we don’t need to, because we can be in the presence with the intrusive thoughts that the OCD is reacting to, just like the presence of all the other thousands of thoughts we have each day without interacting with them.

Kimberley: That’s so interesting. I’ve never thought of it that way. 

Shala: And so, that’s where I’m trying to get people because that is the strongest, strongest recovery, is if you can go do the things that you want to do, be in the presence of the anxiety and not do compulsions physical or mental, you don’t give anything for OCD to work with. I have a whole chapter in my memoir about this after I heard Reid say at one of the conferences, “We need to act as though what OCD is saying doesn’t matter.” And that was revolutionary to me to hear that. And that’s what we’re trying to do both physically and mentally. Because if you can have an obsession and focus on what you want to focus on, do what you want to do, you’re not giving OCD anything to work with. And typically, it’ll just drain away. But this takes time. I mean, it has taken me years to learn how to do this, but I went untreated for 35 years too. It may not take you years, but it may. And that’s okay. It’s a process. And I think if you have trouble trying to do shoulders back, man in the park, use ’may or may nots’. You can use the combination. But I think we’re trying to get to the point where you can just be with the OCD and hear it flipping out and just go on with your day.

OCD, BDD, and Mental Rituals 

Kimberley: In your book, you talk about the different voices. There is a BDD voice and an OCD voice. Was it harder or easier depending on the voice? Was that a component for you in that-- because the words and the voice sound a little different. I know in your memoir you give them different names and so forth, which if anyone hasn’t read your memoir, they need to go right now and read it. Do you have any thoughts on that in terms of the different voices or the different ways in which the disorders interact?

Shala: That’s a really great question because yes, I think OCD does shift its voice and shift its persona based on how scared it is. So, if it’s a little bit scared, it’s probably going to speak to you. It’s still going to be not a very nice voice. It might be urgent and pleading. But if it’s super scared, I talk about mine being like the triad of hell, how my OCD will personify into different things based on how scared it is. And if it’s super scared and it’s going to get super big and it’s going to get super loud in your head because it’s trying desperately to help you understand you’ve got to save it because it thinks it’s in danger. That’s all its content. Then I think-- and if you have trouble ignoring it because it’s screaming in your head, like the man in the park comes over with his megaphone, puts it right up against your ear and starts talking, that’s hard to ignore. That’s hard to act like that’s not relevant because it hurts. There’s so much noise. 

That’s when you might have to use a may or may not type approach because it’s just so loud, you can’t ignore it, because it’s so scared. And that’s okay. And again, sometimes I’ll have to use that. Not too terribly often just because I’ve spent a long time working on how to use the shoulder’s back, man in the park, but if I have to use it, I use it. And so, I think your thought about how do I interact with the OCD based on how aggressive it’s being also plays into this.

Kimberley: I love all this. I think this is really helpful in terms of being able to be flexible. I know sometimes we want just the one rule that’s going to work in all situations, but I think you’re right. I think that there needs to be different approaches. And would you say it depends on the person? Do you give them some autonomy over finding what works for them, or what would you say? 

Shala: Absolutely. If people are up in their heads and they don’t want to use ’may or may nots’, I’ll try to use some other things. If I really, really think that that’s what we need right now, is we need scripting, I’ll try to sell them on why. But at the end of the day, it’s always my client’s choice and I do it differently based on every client. For some clients, it might be just more empowering statements. For some clients where it’s more panicky focused, it might be more about bringing on your anxiety. Sometimes it might be pulling self-compassion in and just saying the self-compassion statements out loud. So, it really does vary by person. There’s no one-size-fits-all, but I think, I feel that people need to have something to replace the mental ritualizing with at the beginning that they’ve been doing it for a long time, just because otherwise, it’s like, I’m giving them a bicycle, they’ve never ridden a bicycle before and I won’t give them any training wheels. And that’s really, really hard. Some people can do it. I mean, some people can just be like, “Oh, I’m to stop doing that in my head? Okay, well, I’ll stop doing that in my head.” But most people need something to help them bridge that gap to get to the point where they can just be in the presence with it and not be talking to it in their heads.

Kimberley: Amazing. All right. Any final statements from you as we get close to the end?

Shala: I think that it’s important to, as you’re working on this, really think about what you’re doing in your head that might be subtle, that could be making the OCD worse. And I think talking and being willing to talk about this to therapists about putting it all out there, “Hey, I’m saying this to myself in my head, is that helpful or harmful?” Because OCD therapy can be pretty straightforward. I mean, ERP, go out and face your fears, don’t do rituals. It sounds pretty straightforward. But there is a lot of subtlety to this. And the more that you can root out these subtle mental rituals, the better that your recovery is going to be. 

And know too that if you’ve had untreated OCD for a long time, you can uncover mental rituals, little bitty ones, for years after you get out of therapy. And that’s okay. It doesn’t mean you’re not in recovery. It just means that you are getting more and more insightful and educated about what OCD is. And the more that you can pick those little things out, just the better your recovery will be. But we also don’t want to be perfectionistic about that like, “I must eliminate every single mental ritual that I have or I’m not going to be in a good recovery.” That’s approaching your ERP like OCD would do. And we don’t want to do that. But we do want to be mindful about the subtleties and make sure to try to pull out as many of those subtle things that we might be doing in our heads as possible. 

Kimberley: Amazing. Thank you. Tell us-- again, first, let me just say, such helpful information. And your personal experience, I think, is really validating and helpful to hear on those little nuances. Tell us where people can hear about you and the amazing projects you’ve got going on.

Shala: You can go to ShalaNicely.com and I have lots of free blog posts I’ve written on this. So, there are two blog posts, two pretty extensive blog posts on ’may or may nots’. So, if you go on my website and just search may or may not, it’ll bring up two blog posts about that. If you search on shoulders back or man in the park, you’ll find two blog posts on how to do that technique. I also have a blog post I wrote in the last year or so called Shower Scripting, which is how to do ERP, like just some touch-up scripting in the shower, use that time. So, I would say go to my website and you can find all sorts of free resources. I’ve got two books. You can find on Amazon, Everyday Mindfulness for OCD, Jon Hershfield and I co-wrote. And we talk about ‘may or may nots’ and shoulders back and some of the things in there just briefly. And then my memoir, Is Fred in the Refrigerator?: Taming OCD and Reclaiming My Life, is also on Amazon or bookstores, Audible, and that kind of thing. 

Kimberley: I wonder too, if we could-- I’m going to put links to all these in the show note. I remember you having a word with your OCD, a video?

Shala: Oh yes, that’s true.

Kimberley: Can we link that too?

Shala: Yes. And that one I have under my COVID resources, because I’m so glad you brought that up. When the pandemic started, my OCD did not like it, as many people who have contamination OCD can relate to. And it was pretty scary all the time. And it was making me scared all the time. And eventually, I just wrote it a letter and I’m like, “Dude, we’re not doing this anymore.” And I read it out loud and I recorded it out loud so that people could hear how I was talking to it. 

Kimberley: It was so powerful.

Shala: Well, thank you. And it’s fun to do. I think the more that you can personify your OCD, the more you can think of it as an entity that is within you but is not you, and to recognize that your relationship with it will change over time. Sometimes you’re going to be compassionate with it. “Gosh, OCD, I’m so sorry,” You’re scared we’re doing this anyway. Sometimes you’re going to be aggressive with it. Sometimes you just ignore it. And that changes as you go through therapy, it changes through your life. And I think that recognizing that it’s okay to have OCD and to have this little thing, I think of like an orange ball with big feet and sunglasses is how I think about it when it’s behaving – it makes it less of an adversarial relationship over time and more like I have an annoying little sibling that, gosh, it’s just not going to ever not be there, but it’s fine. We can live together and live in this uncertainty and be happy anyway.

Kimberley: I just love it. Thank you so much for being here and sharing your experience and your knowledge. It’s so wonderful.

Shala: Thank you so much for having me.

May 6, 2022

SUMMARY:

Covered in This Episode:

  • What is a Mental Compulsion? 
  • What is the difference between Mental Rumination and Mental Compulsions? 
  • How to use Mindfulness for Mental Compulsions
  • How to “Label and Abandon” intrusive thoughts and mental compulsions 
  • How to use Awareness logs to help reduce mental rituals and mental rumination 

Links To Things I Talk About:

Links to Jon’s Books https://www.amazon.com/
Work with Jon https://www.sheppardpratt.org/care-finder/ocd-anxiety-center/

Episode Sponsor:

This episode of Your Anxiety Toolkit is brought to you by CBTschool.com.  CBTschool.com is a psychoeducation platform that provides courses and other online resources for people with anxiety, OCD, and Body-Focused Repetitive Behaviors.  Go to cbtschool.com to learn more. 

To learn about our Online Course for OCD, visit https://www.cbtschool.com/erp-school-lp.

Spread the love!

Everyone needs tools for anxiety...

If you like Your Anxiety Toolkit Podcast, visit YOUR ANXIETY TOOLKIT PODCAST to subscribe free, and you'll never miss an episode. And if you really like Your Anxiety Toolkit, I'd appreciate you telling a friend (maybe even two).

Managing Mental Compulsions (With Jon Hershfield) Your anxiety toolkit

EPISODE TRANSCRIPTION

I want you to go back and listen to that. That is where I walk you through Mental Compulsions 101. What is a mental compulsion, the types of mental compulsions, things to be looking out for. The reason I stress that you start there is there may be things you’re doing that are mental compulsions and you didn’t realize. So, you want to know those things before you go in and listen to the skills that you’re about to receive. Oh my goodness. This is just so, so exciting. I’m mind-blown with how exciting this is all for me.

First of all, let’s introduce the guest for today. Today, we have the amazing Jon Hershfield. Jon has been on the episode before, even talking about mental compulsions. However, I wanted him to status off. He was so brave. He jumped in, and I wanted him to give his ideas around what is a mental compulsion, how he uses mental compulsion treatment with his clients, what skills he uses. Little thing to know here, he taught me something I myself didn’t know and have now since implemented with our patients over at my clinic of people who struggle with mental compulsions. I’ve also uploaded that and added a little bit of that concept into ERP School, which is our course for OCD, called ERP School. You can get it at CBTSchool.com. 

Jon is amazing. So, you’re going to really feel solid moving into this. He gives some solid advice. Of course, he’s always so lovely and wise. And so, I am just so excited to share this with you. Let’s just get to the show because I know you’re here to learn. This is episode two of the series. Next week we will be talking with Shala Nicely and she will be dropping major truth bombs and major skills as well, as will all of the people on the series. So, I am so, so excited. 

One thing to know as you move into it is there will be some things that really work for you and some that won’t. So, I’m going to say this in every episode intro. So, all of these skills are top-notch science-based skills. Each person is going to give their own specific nuanced way of managing it. So, I want you to go in knowing that you can take what you need. Some things will really be like, yes, that’s exactly what I needed to hear. Some may not. So, I want you to go in with an open mind knowing that the whole purpose of this six-part series is to give you many different approaches so that you can try on what works for you. That’s my main agenda here, is that you can feel like you’ve gotten all the ideas and then you can start to put together a plan for yourself. Let’s go over to the show. I’m so happy you’re here.

-----

Kimberley: Welcome, Jon. I’m so happy to have you back.

Jon: Hi, Kimberley. Thanks for having me back.

Difference Between Mental Compulsions and Mental Rumination 

Kimberley: Okay. So, you’re first in line and I purposely had you first in line. I know we’ve had episodes similar to this in the past, but I just wanted to really get your view on how you’re dealing with mental compulsions. First, I want to check in, do you call them “mental compulsions” or do you call it “mental rumination”? Do you want to clarify your own idea?

Jon: Yeah. I say mental compulsions or mental rituals. I use the terms pretty interchangeably. It comes up at the first, usually in the assessment, if not then in the first post-assessment session, when I’m explaining how OCD works and I get to the part we say, and then there’s this thing called compulsions. And what I do is I describe compulsions as anything that you do physically or mentally to reduce distress, and this is the important part, specifically by trying to increase certainty about the content of the obsession. 

Why that’s important is I think we need to get rid of this myth that sometimes shows up in the OCD community that when you do exposures or when you’re triggered, you’re just supposed to freak out and deal with it, and hopefully, it’ll go away on its own. Actually, there are many things you can do to reduce distress that aren’t compulsive, because what makes it compulsive is that it’s acting on the content of the obsession. I mean, there might be some rare exceptions where your specific obsession has to do with an unwillingness to be anxious or something like that. But for the most part, meditation, breathing exercises, grounding exercises, DBT, certain forms of distraction, exercise – these can all reduce your physical experience of distress without saying anything in particular about whether or not the thought that triggered you is true or going to come.

So, once I’ve described that, then hopefully, it opens people up to realize, well, it could really be anything and most of those things are going to be mental. So then, we go through, “Well, what are the different mental ways?” We know the physical ways through washing hands and checking locks and things like that. But what are all the things you’re doing in your mind to convince yourself out of the distress, as opposed to actually working your way through the distress using a variety of distress tolerance skills, including acceptance?

Kimberley: Right. Do you do the same for people with generalized anxiety or social anxiety or other anxiety disorders? Would you conceptualize it the same way?

Mental Compulsions for General Anxiety Disorder vs OCD 

Jon: Yeah. I think for the most part, I mean, I do meet people. Some people who I think are better understood as having generalized anxiety disorder than OCD, and identifying with that concept actually helps them approach this problem that they have of dealing with uncertainty and dealing with worry and dealing with anxiety on close to home, regular everyday issues like finance and work and health and relationships and things like that. And there’s a subsection of that people who, if you treat it like OCD, it’s really helpful. And there’s a subsection if you treat it like OCD, they think, “Oh no, I have some other psychiatric problem I have to worry about right now.”

I’m a fan of treating the individual that the diagnostic terms are there to help us. Fundamentally, the treatment will be the same. What are you doing that’s sending the signal to your brain, that these ideas are threats as opposed to ideas, and how can we change that signal?

Exposure & Response Prevention for Mental Compulsions 

Kimberley: Right. I thank you for clarifying on that. So, after you’ve given that degree of psychoeducation, what do you personally do next? Do you want to share? Do you go more into an exposure option? Do you do more response prevention? Tell me a little bit about it, walk me through how you would do this with a client.

Jon: The first thing I would usually do is ask them to educate me on what it’s really like to be them. And so, that involves some thought tracking. So, we’ll use a trigger and response log. So, I keep it very simple. What’s setting you off and what are you doing? And I’ll tell them in the beginning, don’t try too hard to get better because I want to know what your life is really like, and I’ll start to see the patterns. It seems every time you’re triggered by this, you seem to do that. And that’s where they’ll start to reveal to me things like, “Well, I just thought about it for an hour and then it went away.” And that’s how I know that they’re engaging in mental review and rumination, other things like that. Or I was triggered by the thought that I could be sick and I repeated the word “healthy” 10 times. Okay. So, they’re doing thought neutralization.

Sometimes we’ll expand on that. One of the clinicians in my practice took our thought records and repurposed them as a mental behavior log. So, it’s what set you off. What did you do? What was the mental behavior that was happening at that time? And in some cases, what would’ve been more helpful? Again, I rely more on my patients to tell me what’s going on than on me to tell them “Here’s what’s going on,” so you get the best information.

Logging Mental Rituals 

Kimberley: Right. I love that. I love the idea of having a log. You’re really checking in for what’s going on before dropping everything down. Does that increase their distress? How do they experience that?

Jon: I think a lot of people find it very helpful because first of all, it’s an act of mindfulness to write this stuff down because it’s requiring you to put it in front of you and see it, which is different than having it hit you from inside your head. And so, that’s helpful. They’re seeing it as a thought process. And I think it also helps people come to terms with a certain reality about rumination that it’s not a hundred percent compulsion in the sense that there’s an element of rumination that’s habitual. Your mind, like a puppy, is conditioned to respond automatically to certain things that it’s been reinforced to do. And so, sometimes people just ruminate because they’re alone or sitting in a particular chair. It’s the same reason why people sometimes struggle with hair-pulling disorder, trichotillomania or skin picking. It’s these environmental cues. And then the brain says, “Oh, we should do this now because this is what we do in this situation.” People give themselves a really hard time for ruminating because they’ve been told to stop, but they can’t stop because they find themselves doing it. 

So, what I try to help people understand is like, “Look, you can only control what you can control. And the more that you are aware of, the more you can control. So, this is where you can bring mindfulness into it.” So, maybe for this person, there’s such a ruminator. They’re constantly analyzing, figuring things out. It’s part of their identity. They’re very philosophical. They’re not thinking of it as a compulsion, and many times they’re not thinking of it at all. It’s just happening. And then we increased their awareness, like, “Oh, okay. I got triggered. I left the building for a while. And then suddenly, I realized I was way down the rabbit hole, convinced myself that’s something terrible. So, in that moment I realized I’m supposed to stop, but so much damage has been done because I just spent a really long time analyzing and compulsing and trying to figure it out.” 

So, strategies that increase our awareness of what the mind is doing are extraordinarily helpful because imagine catching it five seconds into the process and being able to say, “Oh, I’m ruminating. Okay, I don’t need to do that right now. I’m going to return my attention to what I was doing before I got distracted.”

Kimberley: Right. I love the idea of this, the log for awareness, because a lot of people say, “Oh, maybe for half an hour a day.” Once they’ve logged it, they’re like, “Wow, it’s four hours a day.” I think it’s helpful to actually recognize this, like how impactful it is on their life. So, I love that you’re doing that piece. You can only control what you can control. What do you do with the stuff you can’t control?

Jon: Oh, you apply heavy doses of self-criticism until you hate yourself enough to never do it again. That’s the other mental ritual that usually happens and people realize, “Oh, I’ve been ruminating,” and they’re angry at themselves. “I should know better.” So, they’re angry at themselves for something they didn’t know they were doing, which is unfair. So, I use the term, I say, “label and abandon.” That’s what you do with all mental rituals. The moment you see it, you give it a name and you drop it. You just drop it on the floor where you were, you don’t finish it up real quick. You don’t analyze too much about it and then drop it. You’re just like, “Oh, I’m holding this thing I must not hold,” and you drop it. Label and abandon.

What people tend to do is criticize then label, then criticize some more and then abandon. And the real problem with that is that the self-criticism is in and of itself another mental ritual. It’s a strategy for reducing distress that’s focused on increasing certainty about the content of the obsession. The obsession, in this case, is “I’m never going to get better.” Now I know I’m going to get better because I’ve told myself that I’m being fooled and that I’ll never do that again. It’s not true. But then you wash your hands. They aren’t really clean either. So, none of our compulsions really work.

Self-Compassion for Mental Compulsions 

Kimberley: Doesn’t have to make sense. 

Jon: Yeah. So, I think bringing self-compassion in the moment to be able to recognize it and recognize the urge to self-criticize and really just say like, “Oh, I’m not going to do that. I caught myself ruminating. Well done.” Same thing we do when we meditate. Some people think that meditation has something to do with relaxation or something to do with controlling your mind. It’s actually just a noticing exercise. Your mind wanders, you notice it. “Oh, look at that, I’m thinking.” Back to the breath. That’s a good thing that you noticed that you wandered. Not, “Oh, I wandered, I can’t focus. I’m bad at meditating.” So, it’s really just changing the frame for how people are relating to what’s going on inside. 

One, eliminating self-criticism just makes life a lot easier. Two, eliminating the self-criticism and including that willingness to just label the thought pattern or the thought process and drop it right where it is. You can start to catch that earlier and earlier and earlier. So, you’re reducing compulsions. And you’ll see that the activity, the neutralizing, the figuring it out, the using your mental strength against yourself instead of in support of yourself, you could see how that’s sending the signal to the brain. “Wait, this is very important. I need to keep pushing it to the forefront.” There’s something to figure out here. This isn’t a cold case in a box, on a shelf somewhere. This is an ongoing investigation and we have to figure it out. How do we know? Because they’re still trying to figure it out.

Kimberley: Right. How much do you think insight has to play here or how much of a role does it play?

Jon: Insight plays a role in all forms of OCD. I mean, it plays a role in everything – insight into our relationships, insight into our career aspirations. I think one of the things I’ve noticed, and this is just anecdotal, is that the higher the distress and the poorer the distress regulation skills, often the lower the insight. Not necessarily the other way around. Some people have low insight and aren’t particularly distressed by what’s going on, but if the anxiety and the distress and the discomfort and disgust are so high that the brain goes into a brownout, I noticed that people switch from trying to get me to reassure them that their fears are untrue to trying to convince me that their fears are true. And to me, that represents an insight drop and I want to help them boost up their insight. And again, I think becoming more aware of your mental activity that is voluntary – I’m choosing to put my mind on this, I’m choosing to figure it out, it didn’t just happen. But in this moment, I’m actually trying to complete the problem, the puzzle – becoming more aware that that’s what you’re doing, that’s how you develop insight. And that actually helps with distress regulation.

Kimberley: Right. Tell me, I love you’re using this word. So, for someone who struggles with distress regulation, what kind of skills would you give a client or use for yourself?

Jon: So, there are many different skills a person could use. And I hesitate to say, “Look, use this skill,” because sometimes if you’re always relying on one skill and it’s not working for you, you might be resistant to using a different skill. In DBT, they have something called tip skills. So, changing in-- drastic changes in temperature, intense exercise, progressive muscle relaxation, pace breathing. These are all ways of shifting your perspective. In a more global sense, I think the most important thing is dropping out of the intellectualization of what’s happening and into the body. So, let’s say the problem, the way you know that you’re anxious is that your muscles are tense and there’s heat in your body and your heart rate is elevated. But there are lots of circumstances in your life where your muscles would be tense and your heart rate will be up and you’ll feel hot, and you might be exercising, for example. 

So, that experience alone isn’t threatening. It’s that experience press plus the narrative that something bad is going to happen and it’s because I’m triggered and it’s because I can’t handle the uncertainty and all this stuff. So, it’s doing two things at once. It’s dropping out of the thought process, which is fundamentally the same thing as labeling and abandoning the mental ritual, and then dropping into the body and saying, “What’s happening now is my hands are sweaty,” and just paying attention to it. Okay, alright, sweaty hands. I can be with sweaty hands. Slowing things down and looking at things the way they are, which is not intellectual, as opposed to looking at things the way they could be, or should be, or might have been, which again is a mental ruminative process.

Kimberley: Right. Do you find-- I have found recently actually with several clients that they have an obsession. They start to ruminate and then somewhere through there, it’s hard to determine what’s in control and what’s not. So, we want to preface it with that. But things get really out of control once they start to catastrophize even more. So, would you call the catastrophization a mental rumination, or would you call it an intrusive thought? How would you conceptualize that with a client? They have the obsession, they start ruminating, and then they start going to the worst-case scenario and just staying there.

Jon: Yeah. There’s different ways to look at it. So, catastrophizing is predicting a negative future and assuming you can’t cope with it, and it’s a way of thinking about a situation. So, it’s investing in a false project. The real project is there’s something unknown about the future and it makes you uncomfortable and you don’t like it. How do you deal with that? That’s worth taking a look at. The false project is, my plane is going to crash and I need to figure out how to keep the plane from crashing. But that’s how the OCD mind tends to work.

So, one way of thinking about catastrophizing is it’s a tone it’s a way-- if you can step back far enough and be mindful of the fact that you’re thinking, you can also be mindful of the fact that there is a way that you’re thinking. And if the way that you’re thinking is catastrophizing, you could say, “Yeah, that’s catastrophizing. I don’t need to do that right now.” 

But I think to your point, it is also an act. It’s something somebody is doing. It’s like, I’m going to see this through to the end and the hopes that it doesn’t end in catastrophe, but I’m also going to steer it into catastrophe because I just can’t help myself. It’s like a hot stove in your head that you just want to touch and you’re like, “Ouch.” And in that case, I would say, yeah, that’s a mental ritual. It’s something that you’re doing. 

I like the concept of non-engagement responses. So, things that you can do to respond to the thought process that aren’t engaging it directly, that are helping you launch off. Because like I said, before you label and abandon. But between the label and abandon, a lot of people feel like they need a little help. They need something to drive a wedge between them and the thought process. Simply dropping it just doesn’t feel enough, or it’s met with such distress because whenever you don’t do a compulsion, it feels irresponsible, and they can’t handle that distress. So, they need just a little boost. 

What do we know about OCD? We know that the one thing you can’t do effectively is defend yourself because then you’re getting into an argument and you can’t win an argument against somebody who doesn’t care what the outcome of the argument is. The OCD just wants to argue. So, any argument, no matter how good it is, the OCD is like, “Great, now we’re arguing again.”

How to Manage Mental Compulsions 

Kimberley: Yeah. “I got you.”

Jon: Yeah. So, what are our options? What are our non-engagement response options? One, which I think is completely undersold, is ignoring it. Just ignoring it. Again, none of these you want to only focus on because they could all become compulsive. And then you’re walking around going, “I’m ignoring it, I’m ignoring it.” And then you’re just actually avoiding it. But it’s completely okay to just choose not to take yourself seriously. You look at your email and it’s things that you want. And then in there is a junk mail that just accidentally got filtered into the inbox instead of the spam box, and mostly what you do is ignore it. You don’t even read the subject of it. You recognize that in the moment, it’s spam and you move on as if it wasn’t even there.

Then there’s being mindful of it. Mindful noting. Just acknowledging it. You take that extra beat to be like, “Oh yeah, there’s that thought.” In act, they would call this diffusion. I’m having a thought that something terrible is going to happen. And then you’re dropping it. So, you’re just stepping back and be like, “Oh, I see what’s going on here. Okay, cool. But I’m not going to respond to it.” And then as we get into more ERP territory, we also have the option of agreeing with the uncertainty that maybe, maybe not. “What do I know? Okay. Maybe the plane is going to crash. I can’t be bothered with this.” But you have to do it with attitude because if you get too involved in the linguistics of it, then it’s like, well, what’s the potential that it’ll happen? And you can’t play that game, the probability game. 

But it is objectively true that any statement that begins with the word “maybe” has something to it. Maybe in the middle of this call, this computer is going to explode or something like that. It would be very silly for me to worry about that, but you can’t deny that the statement is true because it’s possible. It’s maybe. So, just acknowledging that, be like, “Okay, fine. Maybe.” And then dropping it the way you would if you had some thought that you didn’t find triggering and yet was still objectively true. 

And then the last one, which can be a lot of fun, can also be overdone, can also become compulsive, but if done well can make life a little bit more fun, is agreeing with the thought in an exaggerated humorous, sarcastic way. Just blowing it up. So, you’re out doing the OCD. The OCD is very creative, but you’re more creative than the OCD.

Kimberley: Can you give me examples?

Jon: Well, the OCD says your plane is going to crash. He said, your plane is going to crash into a school. Just be done with it, right? And that kind of shock where the bully is expecting you to defend yourself and instead, you just punched yourself in the face. He’s like, “Yeah, you’re weird. I’m not going to bother you anymore.” That’s the relationship one wants with their OCD.

Kimberley: That’s true. I remember in a previous episode we had with, I think it was when you had brought out your team book about saying “Good one bro,” or “brah.”

Jon: “Cool story, brah.” Yeah. 

Kimberley: Cool story brah. And I’ve had many of my patients say that that was also really helpful, is there’s a degree of attitude that goes with that, right?

Jon: Yeah. And because again, it’s just a glitch in the system that, of course, you’re conditioned to respond to it like it’s serious. But once you realize it is, once you get the hint that it’s OCD, you have to shift out of that, “Oh, this is very important, very serious,” and into this like, “This is junk mail.” And if you actually look at your junk mail, none of it is serious. It sounds serious. It sounds like I just inherited a billion dollars from some prince in Nigeria. That sounds very important. I

Kimberley: I get that email every day pretty much. 

Jon: Yeah. But I look at it and immediately I know that it’s not serious, even though the words in it sound very important. 

Kimberley: Yeah. So, for somebody, I’m sitting in the mind of someone who has OCD and is listening right now, and I’m guessing, to those who are listening, you’re nodding and “Yes, this is so helpful. This is so helpful.” And then we may finish the episode and then the realization that “This is really hard” comes. How much coaching, how much encouragement? How do you walk someone through treatment who is finding this incredibly difficult?

Jon: I want to live in your mind. In my mind, let that same audience member is like, “This guy sucks.”

Kimberley: My mind isn’t so funny after we start the recording. So, you’re cool.

Jon: Who is this clown? Again, it’s back to self-compassion. I’m sure people are tired of hearing about it, but it’s simply more objective. It is hard. And if you’re acting like it shouldn’t be hard or you’re doing something wrong as a function, it’s hard because you’re doing something wrong, you’re really confused. How could that be? You could not have known better than to end up here. Everything that brought you here was some other thought or some other feeling, and you’re just responding to your environment. The question is right now where you have some control, what are you going to do with your attention? Right now, you’re noticing, “Oh man, it’s really hard to resist mental rituals. It’s hard to catch them. It’s hard to let go of them. It’s hard to deal with the anxiety of thinking because I didn’t finish the mental ritual. Maybe I missed something and somebody’s going to get hurt or something like that because I didn’t figure it out.” 

It is really hard. I don’t think we should pretend that it’s easy. We should acknowledge that it’s hard. And then we should ask, “Okay, well, I made a decision that I’m going to do this. I’m going to treat my OCD and it looks like the treatment for OCD is I’m going to confront this uncertainty and not do compulsions. So, I have to figure out what to do with the fact that it’s hard.” And then it’s back to the body. How do you know that it’s hard? “Well, I could feel the tension here and I could feel my heart rate and my breath.” So, let’s work with that. How can I relate to that experience that’s coming up in a way that’s actually helpful?

The thing that I’ve been thinking about a lot lately is this idea that the brain is quick to learn that something is dangerous. Something happens and it hurts, and your brain is like, “Yeah, let’s not do that again.” And you might conclude later that that thing really wasn’t as dangerous as you thought. And so, you want to re-engage with it. And you might find that’s really hard to do, which is why exposure therapy is really hard because it’s not like a one-and-done thing. You have to practice it because the brain is very slow to learn that something is safe, especially after it’s been taught that it’s dangerous.  But that’s not a bad thing. You want a brain that does that. You don’t want a brain that’s like, “Yeah, well, I got bit by one dog, but who cares? Let’s go back in the kennel.” You want a brain that’s like, “Hold on. Are you sure about this?”

That whole process of overcoming your fears, I think people, again, they’re way too hard on themselves. It should take some time and it should be slow and sluggish. You look like you’re getting better, and then you slip back a little bit, because it’s really just your brain saying, “Listen, I’m here to keep you safe, and I learned that you weren’t, and you are not following rules. So, I’m pulling you back.” That’s where that is coming from. So, that’s the hard feeling. That’s the hard feeling right there. It’s your brain really trying to get you to say, “No, go back to doing compulsions. Compulsions are keeping you safe.” You have to override that circuit and say, “I appreciate your help. But I think I know something that you don’t. So, I’m going to keep doing this.” And then you can relate to that hard feeling with like, “Good, my brain works. My brain is slow and sluggish to change, but not totally resistant. Over time, I’m going to bend it to my will and it will eventually let go, and either say this isn’t scary anymore or say like, ‘Well, it’s still scary, but I’m not going to keep you from doing it.’”

Kimberley: Right. I had a client at the beginning of COVID I think, and the biggest struggle-- and this was true for a lot of people, I think, is they would notice the thought, notice they’re engaging in compulsions and drop it, to use your language, and then go, “Yay, I did that.” And then they would notice another thought in the next 12 seconds or half a second, and then they would go, “Okay, notice it and drop it.” And then they’d do it again. And by number 14, they’re like, “No, this is--” or it would either be like, “This is too hard,” or “This isn’t working.” So, I’m wondering if you could speak to-- we’ve talked about it being “too hard.” Can you speak to your ideas around “this isn’t working”?

Jon: Yeah. That’s a painful thought. I think that a lot of times, people, when they say it isn’t working, I ask them to be more specific because their definition of working often involves things like, “I was expecting not to have more intrusive thoughts,” or “I was expecting for those thoughts to not make me anxious.” And when you let go of those expectations, which isn’t lowering them at all, it’s just shifting them, asking, well, what is it that you really want to do in your limited time on this earth? You’re offline for billions of years. Now you’re online for, I don’t know, 70 to 100 if you’re lucky, and then you’re offline again. So, this is the time you have. So, what do you want to do with your attention? And if it’s going to be completely focused on your mental health, well, that’s a bummer. You need to be able to yes, notice the thought, yes, notice the ritual, yes, drop them both, and then return to something. 

In this crazy world we’re living in now where we’re just constantly surrounded by things to stimulate us and trigger us and make us think, we have lots of things to turn to that aren’t necessarily healthy, but they’re not all unhealthy either. So, it’s not hard to turn your attention away from something and into a YouTube video or something like that. It is more challenging to shift your attention away from something scary and then bring it to the flavor of your tea. That’s a mindfulness issue. That’s all that is. Why is one thing easier than the other? It’s because you don’t think the flavor of your tea is important. Why? Because you’re just not stimulated by the firing off of neurons in your tongue and the fact that we’re alive on earth and that we’ve evolved over a million years to be able to make and taste tea. That’s not as interesting as somebody dancing to a rap song. I get that, but it could be if you’re paying a different kind of attention.

So, it’s just something to consider when you’re like, “Well, I can’t return to the present because it doesn’t engage me in there.” Something to consider, what would really engage you and what is it about the present that you find so uninteresting? Maybe you should take another look.

Kimberley: Right. For me, I’m just still so shocked that gravity works. Whenever I’m really stuck, I will admit, my rumination isn’t so anxiety-based. I think it’s more when I’m angry, I get into a ruminative place. We can do that similar behavior. So, when I’m feeling that, I have to just be like, “Okay, drop away from, that’s not helpful. Be aware and then drop it.” And then for me, it’s just like, “Wow, the gravity is pulling me down. It just keeps blowing my mind.”

Jon: Yeah. That’s probably a better use of your thought process than continuing to ruminate. But you bring up another point. I think this speaks more closely to your question about when people say it’s not working. I’m probably going to go to OCD jail for this, but I think to some extent, when you get knocked off track by an OCD trigger, because you made me think of it when you’re talking about anger. Like, someone says something to you and makes you angry and you’re ruminating about it. But it’s the same thing in OCD. Something happens. Something triggers you to think like, “I’m going to lose my job. I’m a terrible parent,” or something like that. You’re just triggered. This isn’t just like a little thought, you’re like, “Oh, that’s my OCD.” You can feel it in your bones. It got you. It really got you. 

Now, you can put off ruminating as best you can, but you’re going to be carrying that pain in your bones for a while. It could be an hour, could be a day, could be a couple of days. Now, if it’s more than a couple of days, you have to take ownership of the fact that you are playing a big role in keeping this thing going and you need to change if you want different results. But if it’s less than a couple of days and you have OCD, sometimes all you can do is just own it. “All right, I’m just going to be ruminating a lot right now.” And I’m not saying like, hey, sit there and really try to ruminate. But it’s back to that thing before, like your brain is conditioned to take this seriously, and no matter how much you tell yourself it’s not serious, your brain is going to do what your brain is going to do. And so, can you get your work done? Try to show up for your family, try to laugh when something funny happens on TV, even while there’s this elephant sitting on your chest. And every second that you’re not distracted, your mind is like, “Why did they say that? Why did I do that? What’s going to happen next?” And really just step back from it and say like, “You know what, it’s just going to have to be like this for now.”

What I see people do a lot is really undersell how much that is living with OCD. “I’m not getting better.” I had this happen actually just earlier today. Somebody was telling me, walking me through this story that was just full of OCD minds that they kept stepping on and they kept exploding and they were distressed and everything. And yet, throughout the whole process, the only problem was they were having OCD and they were upset. But they weren’t avoiding the situation. They weren’t asking for reassurance and they weren’t harming themselves in any way. They were just having a rough time because they just had their buttons pushed. It was frustrating because they wouldn’t acknowledge that that is a kind of progress that is living with this disorder, which necessarily involves having symptoms. 

I don’t want people to get confused here and say like, “This is as good as it gets,” or “You should give up hope for getting better.” It’s not about that. Part of getting better is really owning that this is how you show up in the world. You have your assets and your liabilities, and sometimes the best thing to do is just accept what’s going on and work through it in a more self-compassionate way.

Kimberley: Right. I really resonate with that too. I’ve had to practice that a lot lately too of accepting my humanness. Because I think there are times where you catch yourself and you’re like, “No, I should be performing way up higher.” And then you’re like, “No, let’s just accept these next few days are going to be rough.” I like that. I think that that’s actually more realistic in terms of what recovery really might look like. This is going to be a rough couple of days or a rough couple of hours or whatever it may be.

Jon: Yeah. If you get punched hard enough in the stomach and knock the wind out of you, that takes a certain period of time before you catch your breath. And if you get punched in the OCD brain, it takes a certain amount of time before you catch your breath. So, hang on. It will get better. And again, this isn’t me saying, just do as many compulsions as you want. It’s just, you’re going to do some, especially rumination and taking ownership of that, “Oh man, it’s really loud in there. I’ve been ruminating a lot today. I’ll just do the best I can.” That’s going to be a better approach than like, “I’m going to sit and track every single thought and I’m going to burn it to the ground. I’m going to do it every five seconds.” Really, you’re just going to end up ruminating more that way.

Kimberley: Right. And probably beating yourself up more.

Jon: Exactly.

Kimberley: Right. Okay. I feel like that is an amazing place for us to end. Before we do, is there anything you feel like we’ve missed that you just want people to know before we finish up?

Jon: I guess what’s really important to know since we’re talking about mental compulsions is that it’s not separate from the rest of OCD and it’s not harder to treat. People have this idea that, well, if you’re a compulsive hand-washer, you can just stop washing your hands or you can just remove the sink or something like that. But if you’re a compulsive ruminator about whether or not you’re going to harm someone or you’re a good person or any of that stuff, somehow that’s harder to treat. I’ve not found this to be the case. Anecdotally, I haven’t seen any evidence that this is really the case in terms of research. You might be harder on yourself in some ways, and that might make your symptoms seem more severe, but that’s got nothing to do with how hard you are to treat or the likelihood of you getting better.

Most physical rituals are really just efforts to get done what your mental rituals are not doing for you. So, many people who are doing physical rituals are also doing mental rituals and those who aren’t doing physical rituals. Again, some people wash their hands. Some people wash their minds. Many people do both. A lot of this stuff, it has to do with like, “I expect my mind to be one way, and it’s another.” And that thing that’s making it another is a contaminant, “I hate it and I want to go away and I’m going to try to get it to go away.” And that’s how this disorder works.

Kimberley: Right. It’s really, really wonderful advice. I think that it’s actually really great that you covered that because I think a lot of people ask that question of, does that mean that I’m going to only have half the recovery of someone who does physical compulsions or just Googles or just seeks reassurance? So, I think it’s really important. Do you feel like someone can overcome OCD if their predominant compulsion is mental?

Jon: Absolutely. They may even have assets that they are unaware of that makes them even more treatable. I mean, only one way to find out.

Kimberley: Yeah. I’m so grateful to you. Thank you for coming on. This is just filling my heart so much. Thank you.

Jon: Thank you. I always love speaking with you.

Kimberley: Do you want to share where people can find you and all your amazing books and what you’re doing?

Jon: My hub is OCDBaltimore.com. That’s the website for the Center for OCD and Anxiety at Sheppard Pratt, and also the OCD program at The Retreat at Sheppard Pratt. And I’m on Instagram at OCDBaltimore, Twitter at OCDBaltimore. I don’t know what my Facebook page is, but it’s out there somewhere. I’m not hard to find. Falling behind a little bit on my meme game, I haven’t found anything quite funny or inspiring enough. I think I’ve toured through all of my favorite movies and TV shows. And so, I’m waiting for some show that I’m into to inspire me. But someone asked me the other day, “Wait, you stopped with the memes.”
Kimberley: They’re like, nothing’s funny anymore.

Jon: I try not to get into that headspace. Sometimes I do think that way, but yeah, the memes find me. I don’t find them.

Kimberley: I love it. And your books are all on Amazon or wherever you can buy books, I’m imagining.

Jon: Yes. The OCD Workbook For Teens is my most recent one and the second edition of the Mindfulness Workbook for OCD is also a relatively recent one.

Kimberley: Amazing. You’re amazing. Thank you so much.

Jon: Thank you.

1