Before we get to starting real behavior therapy with what we call our "behavior therapy primer," how did you do with your post-OCD vision homework? Did that exercise raise any questions for you? Were you able to compose at least five short sentences? What held you back if you had trouble? This may seem like a silly task, but it's important enough so that if you had difficulty, please try again. There are a couple of things that you might think about when trying to compose this post-OCD vision plan. First, you will probably be experiencing less anxiety in your daily life, and because you won't be spending as much time having obsessive thoughts or performing compulsions, you will probably also have more free time during your day than you have now. How will these things affect your job? Your schooling? Most importantly, your relationships? If you can get in touch with this, how might it affect your view of yourself? Remember that these changes may not necessarily affect any one of these; one past client was upset with this assignment, stating that he was happy with the way he was now, but he just wanted to get rid of his obsessions and compulsions! The point is that most of you are probably aware that much of what you are and do is OK; we don't want you to change that. But taking away the OCD symptoms will have an impact on your life. It's as if we are starting on a journey: along the road you will be treating your OCD and you will be gaining the choice to shed your symptoms. If your particular ritual has a function for you, you can always retain it, or bring it back for later use, but at least you will have the choice. But as for any other trip, it's very helpful to know your destination before you get started in earnest. This vision plan is designed to get you started thinking about the destination.

Let's talk about behavior therapy for OCD. This first thing to know is that all changes take time. Many of you have had your OCD for several years, and you can't expect to change all of your symptoms, habits, thoughts and beliefs overnight. That said, behavior therapy is the best road currently known to get to your destination of reduced (or eliminated) OCD symptoms. The type of therapy best supported by the literature is Exposure and Response Prevention, or E & RP. Exposure means being exposed (or exposing yourself) to your anxiety-producing stimuli, the things you normally avoid or the things that you fear. Response prevention means inhibiting yourself from doing the behavior, or the ritual, that you normally use to temporarily reduce your anxiety. Sounds awful, huh? It sounds like asking you to face your dragons and taking away your sword and shield. For instance, someone with contamination fears may avoid touching the trash can, or may wash their hands several times after touching it. With an E & RP approach, that person would be volunteering to touch the can deliberately, and then refrain from washing for at least an hour. Now this may sound intimidating, but we do this in the way that starts you out with something that doesn't bother you very much, and work up to the most difficult tasks at a rate you feel comfortable with. The best treatment for OCD is to pair these two strategies together. Now sometimes that's not practical. For instance if we're treating an obsession like "I'm afraid I might kill my kid," it may occur with a ritual like saying a prayer. Or it may actually occur alone without a ritual. In that case, we might use exposure alone by exposing the person over and over again to the obsession until it loses it's value, which is what we've called flooding. Alternatively we might use ritual prevention alone. This is useful in cases where there is a behavior without anxiety (like trichotillomania or compulsive skin picking), or where there is no associated obsession (like hoarding). Here we would simply ask people to monitor what they're doing, like to journal their hair pulling, or to tape their pulled eyelashes to a card, or to simply not do a certain part of their ritual and to report to us later how they did with their attempt. Now we have to be careful about that, because a lot of rituals are things people can't "just stop doing." We're not talking about that kind of "not doing it," but rather taking the ritual apart piece by piece and stopping certain parts that the person knows they can handle in an isolated way. In doing this, we're actually helping the person regain control of the ritual. So we can use either of these alone, but whenever we can it's best to pair them. So that is what we will try to aim for when your symptoms allow the paired approach.

When we ask you to do the thing that normally increases your anxiety, and then ask you not to do the thing that normally reduces your anxiety, what do you think will happen? I mean, besides the formation of a lynch mob. Right, your anxiety will go up. And it seems like it won't go back down. What an awful situation; how dare we ask you to do something like that! Some of you must think we're joking. Well, we're not joking, but we're also not asking you to expose yourself to any more anxiety than you are ready for. From the beginning, you will have complete control over how much anxiety you experience, and if you don't feel ready to do it, then you sid�� e�`to do it. Abпt isn't true that your anxiety won't come back down. Let me diagram the situation (see Figure 12). Let's draw time on the X-axis going out to about an hour, and Y-axis we'll call anxiety. We'll be starting at your baseline level of anxiety, positive but not too high. Now a couple of minutes out on the X-axis you'll be exposing yourself to your anxiety-producing stimulus, and all of a sudden your anxiety goes up, to whatever the peak value is for you. What would normally happen is that your anxiety would peak, then you would do your ritual and your anxiety would come back down as it tapers back to baseline. Now what happens if we ask you not to do your ritual? Well, your anxiety will stay up; pretty scary thought, huh? However, over time your anxiety starts to come back down, by itself, without doing your ritual - all the way back to its original level. What this chart shows is really the basis of Exposure and Response Prevention - even if you don't do your ritual, your anxiety will eventually come back down by itself. With E & RP and with your hierarchies and with your repeated exposures we will be reinforcing that notion. We will in effect be training your brain to know that your anxiety will come back down after each exposure.

Now, it's nice to have a little safety net when we're doing something that feels risky. You may be saying to yourself, "sometimes it feels like my anxiety stays up for a long time." It really might; more likely, it really comes back down sooner but it feels like it stays up a long time. Anxiety is not fun to live with, and it may feel like it stays up for a while. The way we structure the assignments is that if your anxiety doesn't come back down after an hour, if you still feel the need to do the ritual after 60 minutes, then go ahead and do it. That's the deal that we make. What will probably happen is that your anxiety will come back down, and you won't feel that there's enough anxiety to worry about. Or, especially in the beginning, you may not even remember to do it. However, the caveat is that you can't just sit there like this, with your hands up in the air for an hour after touching a contaminated object and wait it out. You have to go on with the rest of your life. If you just sit there, not only will it take up an hour of your precious time, but you will also propagate in your mind the idea that your hands are really contaminated. So go about whatever you were doing as if you hadn't experienced any anxiety. Eventually you will be able to separate the anxiety from the exposure, and your brain will learn that they are two separate things and that you do not have to do the ritual in order for the anxiety to come back down by itself.

The Hierarchy. The principle tool of E & RP is called the hierarchy. This is the single most important thing we will do in the six chapters, because you can't do this type of behavior therapy for OCD without it. The hierarchy is a graduated list of all the things that you do that make you anxious, that you think that make you anxious, or that you avoid because they make you anxious. Now you write these down in a very particular way; we'll all do an example of this in a few minutes, so if you don't quite get it right now, that's OK. You write these items down as short sentences, so that if you did these things as written, you would get anxious. For instance, one item might be touching the trash can without washing your hands, or touching the trash can without wearing gloves, or touching the trash can without using a paper towel. So you can see that I'm stating both the exposure and the response prevention in each item on the hierarchy, so there's no question about what the RP is going to be. Now we realize that with some items you won't be able to do this, as we talked about earlier. You may be only doing exposure, so you might write "having the thought that I might kill my child," and there wouldn't be any RP. Other examples are "going to bed without checking all the doors in the apartment," or "going to bed without checking the lock on the door." Or you might just be doing RP alone, so you might write "not checking my eyelashes in the mirror in the morning." And some of the things will be things you avoid simply because they make you anxious. If you avoid public speaking, then simply speaking in public will be an item on your hierarchy. These are examples of what might be on the hierarchy.

Group Hierarchy. In the six-week group, we would do a group hierarchy together here for an example. This is something we can all share in. Anyone who wants to would submit something to put on the list, something that makes them anxious, and we would try to phrase it in the E & RP way if at all possible. Even the support people here can contribute, by the way, since we all feel anxious at some time. I usually start with a few personal examples. One that I like to use, that I find people can identify with, is that if I lose my keys (that's my exposure) and I can't look for them right away, I feel anxious. So I'll write this as "losing keys and not looking for them." Now one of my old colleagues had one that he used to mention. If he went to mail a letter, and didn't stop in front of the mailbox to check to see if each letter had a stamp, it made him anxious. This was true even though he knew rationally that he had stamped each letter at home, and had even checked for the return address; he still felt he had to check one last time. So, "mailing letters without checking for stamps." Another example would be one from one of my friends: starting out on a trip without looking at a map first makes him anxious; he's a very planned and organized individual. One final one from me: jumping out of an airplane with a parachute that is not guaranteed to open would cause me a lot of anxiety. This may seem like a silly example to some of you, but we might need to have an example of impossibly high anxiety on our list as well as some little ones. [Here, we would collect 10-15 examples from group, writing them on the board]