SUDs------------Exposure--------------------and----------Response Prevention

100--------Going away for a day-------------and---------not checking the door lock
100--------Touching the toilet seat bottom--and---------not washing my hands
100--------Imagining myself stabbing my kids
100--------Throwing away unopened boxes from the garage
90---------Going away for half a day--------and---------not checking the door lock
90---------Throwing away opened (but unsorted) boxes from the garage
85---------Cleaning the toilet--------------and---------not washing my hands
85---------Imagining myself holding a knife to my kids
80---------Holding a knife in the room with my kids
70---------Taking out a leaking garbage bag-and---------not washing my hands
70---------Imagining myself holding a knife in the room with my kids
70------Going to sleep at night at my house-and---------not checking the door lock
60---Going to sleep at night at mom's house-and---------not checking the door lock
60---------Throwing out advertizing mail----and---------not checking inside for coupons
60---------Walking out of a room------------and---------not turning off the light
50--------Taking out a sealed garbage bag---and---------not washing my hands
50--------Throwing out a manilla envelope---and---------not checking inside for coupons
50---------Going away for an hour-----------and---------not checking the door lock
40---------Throwing out a white envelope----and---------not checking inside for coupons
35---------Having a knife on the table in the room with my kids
30---------Opening a white envelope---------and---------not checking inside for coupons
30---------Walking out of a room------------and---------not closing the door
30---------Driving down the block and back--and---------not checking the house door lock
25---------Touching the trash can-----------and---------not washing my hands
25---------Mailing a letter-----------------and---------not checking for a stamp
20---------Touching a clean trash can-------and---------not washing my hands
20---------Closing the door from the outside-and--------not checking the house door lock
10---------Saying the word "knife"

Chapter VI: Preparing an individual behavior therapy plan

In this chapter we try to address possible problems putting together the hierarchy or choosing an assignment to work on. Often the major difficulty is in determining the lower-level anxiety-producers. Most of us don't have too much trouble identifying our 100s, since they are the things that plague us with greatest anxiety. You may have to struggle to find the 10s and 20s, but it's essential to have them to start out with. If you have this problem, one way to select some is to find the lowest valued item on your hierarchy, and qualify it by adding to it things that make you feel safer, more secure and/or less anxious. For instance, if your obsession has to do with contamination, and your compulsion is to wash your hands after touching the trash, what about touching the trash with someone you trust in the room with you? Not to reassure you verbally, but just to be there. Would that lower your anxiety? It might, but let's suppose that it wasn't enough to get the anxiety down to a 20 for a first assignment. Then you might add touching the trash with a trusted person in the room in the morning. That way you would have the whole day to monitor your anxiety and make sure nothing bad happens. Each of you will be different, and will have different things that you know will make you feel more secure. These things that you add don't diminish the value of the assignment to you, even thought they diminish the amount of anxiety you feel. It's very important to remember that, in behavior therapy, it's better to succeed at something that was too easy for you than to try something that is too hard and not be able to do it. The other value of this approach is that it helps you make things on your hierarchy more specific, and each variation that you come up with should be listed as a separate item on your list, even if some of the conditions create about the same amounts of anxiety. This way, if your trusted person isn't available but your dog is, and the same anxiety reduction value is achieved with Fido, then you don't have to wait to do this assignment. We'll come back to this in a minute.

There are other ways of coming up with low level items, as well as qualifying higher-level items. One way is to ask other people what makes them anxious. Some of the things they mention will make you anxious as well, as we observed last week making up the group hierarchy. But other things that people mentioned, if you remember, didn't make you nearly as anxious as they made the person who suggested them (or maybe they didn't make you anxious at all). This may give you some ideas of things that make you mildly anxious. Another way to dream up low-level items is to think of something that doesn't make you anxious at all, and then add something to it that would make you slightly anxious. For instance, suppose going to bed isn't particularly anxiety-producing for you. What about going to bed and intentionally leaving open the cupboard doors, or the closet doors? This might be one example of a way to develop a slightly anxiety-producing item.

We talked before about adding qualifications to your items as a way of making them less stressful. This also helps make them more specific, and this is another potential trouble spot for us as we create the hierarchy. This approach would include setting times that are easier than others to do certain things, doing them with other people or without, having something to do afterward or not, etc. You can probably dream up hundreds of ways to qualify items, but if not don't worry. We'll help you make them more specific when we get to behavior therapy. And you may not even know that an item is not specific until you try to do it and find out that the level of anxiety you experience isn't what you thought it was (for instance, it was lower than you expected because when you did the assignment, you were in a certain condition that you didn't anticipate). This kind of thing happens often, and it's one of the things that the group can help you understand. So, the message again is be as specific as possible.

We need to mention two other potential problem areas. What if I have obsessions without compulsions? As we mentioned last week, not everything is going to fit neatly into the exposure and response prevention model, and sometimes we can only use one or the other. For obsessions without compulsions, we might simply have to use imaginal exposure. That might mean imagining a lower-level version of your obsession over and over, on a regular basis, either by reading out loud a story about your obsession, or by listening to a tape of yourself reciting it. It seems to make a big difference if you actually hear the words, probably because the brain processes things it hears differently from things you read or things you think. Your hierarchy would have to include many versions of your obsession, each representing different levels of anxiety for you. For instance, if your obsession is "I might harm my dog," one level might be, under conditions where you know that she is safe in her owner's arms, imagining harming her. Another might be, when you know she is safe in bed, but no one else is there to protect her, imagining harming her. Another level is imagining harming her when she is there in front of you at a distance. Another level would be imagining harming her when she is on your lap. Now all of us may experience our level of anxiety going up as I suggest this, since this is not a pleasant thought. For these types of situations it is important to remember that, for OCD sufferers, the things that we obsess about are the last things we are likely to do in real life. It kind of makes sense, doesn't it? These obsessions are horrific to us, and we worry so much about doing these things that we become hypersensitive to them. So, in effect, we are the last people who would ever really do these things. It sometimes helps to remember this if you're going through an exposure for an obsession. Of course, even this is rational reassurance, and we know that rational arguments don't often defeat irrational fears. So it might actually help others more than it would help you to know that you are the last person likely to act out on your obsessions.

The other area of potential problems is compulsions without obsessions. This might be compulsive hair pulling or skin picking, some types of hoarding, or perhaps some "just-so" compulsion that used to be related to an obsession but has become disconnected from it. These represent special problem areas, since often there is no precipitating anxiety that leads to the compulsion. For these types of problems we would likely use response prevention alone. As we mentioned last time, response prevention often starts with response monitoring. For instance, if your compulsion is hair pulling, you probably already know what conditions are likely to permit that behavior, and which conditions don't permit it. You might find that you're more likely to pull when you are reading, or watching TV, or are distracted by something else. Then you might try keeping a log of the times and conditions under which you actually pull, and you might tape the hairs into your log book. Once you do these things, you might have some exposures that are less likely to result in pulling and some that are more likely. For instance, a low-likelihood condition might be when you are involved in an activity with other people. A higher-likelihood one might be being involved in an activity alone, and the still higher would be watching TV alone, and then doing nothing alone. This way you can build up a hierarchy of likelihoods, similar to the anxiety-based hierarchy we've been talking about. Exposing yourself to the less likely situations first, with the intent of monitoring and inhibiting your compulsions, will be the first step up this ladder. In many cases, we may suggest that you use a competing movement or muscle contraction (called a "competing response"), like squeezing your fist or pulling a Koosh ball instead of pulling your hair. You probably can't do both at the same time. Pairing that competing response with a relaxation response (as we talked about in Chapter 2) is a variant of behavior therapy called Habit Reversal Training, or HRT. This is the behavior therapy of choice for impulse sontrol problems. This is close to E&RP (except that in HRT you actually use relaxation instead of allowing the anxiety to dissipate), and is very useful in cases of compulsions without obsessions.

Before we talk about other variants of behavior therapy, remember that not everything that makes us anxious should be changed; some of these things should make us anxious. So if you find that your hierarchy contains items that make you anxious, but you have no desire to change them (that is, you like them the way they are), cross them out. We don't want to help you change anything you don't want to change.

Definitions of other behavioral techniques. Of course, there will be items that don't fit neatly into this model, and we want to talk a little bit about some of the other techniques in behavior therapy that you may or may not have heard about, ones that are used by behavior therapists to help treat anxiety disorders. We'll go over a few with definitions and examples, and we will concentrate on the ones most useful for treating OCD.

We've talked about Exposure and Response Prevention, and this is the technique that the literature supports as being the most useful approach to treating OCD. But some behaviors don't lend themselves to E & RP very well; I'm sure you will be able to think of some as we discuss that approach more. But for example, suppose someone has a problem feeling that they have showered enough to be clean, and their showers are taking one, two, three, even four hours. If they have a particular ritual in the shower - and by the way, all of us do to some degree: just try washing in reverse order, or bottom to top some time - then they might be able to expose themselves to the shower and not engage in some particular part of the ritual. Often this is hard to do if the problem is simply repeated or continuous washing "until it feels right." Here we might use an approach called Behavior Shaping. We would simply reduce the amount of time spent in the shower gradually, say by taking off 5 or 10 minutes the first week, 5 more the next week, etc. After a couple of weeks we would have "shaped" the shower down to whatever the person feels is a reasonable time. This also is voluntary and self-controlled; people use a timer to determine the length of time they can stay in, and they agree to live with any residual anxiety left if they "don't quite feel done yet." Over time this anxiety fades away, and it reinforces the notion that you can take a shorter shower and nothing bad will happen.

Another approach that is very similar to E & RP is called systematic desensitization. This is the treatment of choice for people with phobias, or fears about particular things (like snakes, heights, spiders, or groups) or processes (like flying or public speaking). This uses a series of exposures to the anxiety producing stimuli in a hierarchical fashion like E & RP, but there's a big difference. With OCD, you have to experience the anxiety in order for the treatment to help. With phobias, the idea is to reduce the anxiety from the very beginning. So in systematic desensitization, we pair the exposure to the anxiety-producing stimulus with a state of relaxation as we work up the hierarchy. For instance, if you had a phobia of snakes, we might suggest at first that you imagine a snake on the ground while you are relaxing to soft music in a safe place and doing some diaphragmatic breathing. Then we would move to the next item on your hierarchy. That approach doesn't work well for OCD, so we won't use that in here. It's good to know what it is in case you hear about it somewhere else, or in case you ever seek treatment for a phobia.

You might be asking now, "if I'm not supposed to be reducing my anxiety, why am I here at all, and why are you teaching us relaxation techniques?" Well, the E & RP approach does result in reduced anxiety over the long run, and it results in fewer obsessions and compulsions at the same time. Just reducing your anxiety isn't enough to treat those things. However, we want to make sure that you can do these exposures in a logical fashion, one that won't overwhelm you with difficulty. So we've spent time during the last two weeks of this group working out an ordered approach for your individual assignments, to be accomplished at a rate that you determine with our help. In the meanwhile, there are times that things in your life, other than the items you happen to be working on at the moment, will cause you anxiety, and we're trying to give you some tools to deal with these occurrences. So until you start working on specific assignments, you're free to use whatever methods help you to reduce your daily stress and anxiety.

There's a technique that we call Imaginal Exposure that we mentioned briefly before; some people also call it Flooding. Basically it means imagining the anxiety producing exposure, and staying with the anxiety until it starts to fade on its own. We already practiced a version of this in the homework assignment from the second chapter. This is something that can raise anxiety and resistance to further treatment if not done correctly, so we will have to be careful about when and with whom we do this. But you might be able to suppose that imagining an exposure would be less anxiety producing than having a real exposure, especially if you're aware of the built-in safety of being able to stop the image when you want to.

Now sometimes we can't stop certain images or thoughts when we want to; these are most often obsessions, and they are not only unpleasant to have but difficult to dismiss. Because they are not behaviors, we usually can't do a Response Prevention for a simple obsession. But we can teach a few thought-stopping techniques. These are ways that you can abort, inhibit and even prevent some of your obsessions. In the group, I would use a volunteer, someone who has real obsessions. The best way to learn a new technique is to be involved in a demonstration. I would have them come up near me and sit down. I'd have them close their eyes, relax and allow themselves to have an obsession, one that normally bothers them. I would even reassure them that right now it's OK to have it, and they won't have to say anything about it out loud. I would ask them that, when they're in the middle of their obsession, experiencing it fully, to nod their head. [Here, I wait for client to nod their head. Then I stomp my foot, clap my hands and yell "Stop!" near the client's face] This usually makes everyone in the room jump a bit. I then ask, "did it stop your obsession?" It usually does. Then, I ask the volunteer to close their eyes and have their obsession just like last time. But this time, when they nod their head to let us know they're having their obsession, they stomp they their foot, clap their hands and yell "Stop!" [Wait for client to do this] I ask then, "did it work this time?" Usually it does, at least partly because you have to concentrate on getting ready to stomp, clap and yell. Now we try it one more time. This time, they do everything as they did before, but they don't really move or speak. When they get to the "Stop!" part, they do it all silently, in their mind. [Wait for client to do this] People usually say that this one takes a little practice, because it's harder to shock yourself if you have to imagine it. But try this several times, and don't get discouraged if it doesn't work right away. When you practice it enough, it can be a real help. In addition, some people find that if you replace the now missing obsession with a positive or pleasant thought (one you've already pre-selected), the obsession tends to stay away even longer.

Now, here's one that hardly requires any practice. Wear a rubber band on your wrist, and when you start having an obsession at a bad time, just snap the rubber band. The sting will make you concentrate on your wrist, and it will be difficult for you to keep your obsession in mind. This is because pain, even slight pain, will be the stimulus that the brain chooses to attend to over any other, even over obsessions. If you do this one too much, of course, your wrist will get sore, so try to do this in moderation. But this is a simple technique that works very often, and is a good place to start. In fact, some people say that after trying the rubber band a couple of times, all they needed to do was to imagine the snap and that was enough to stop the thoughts.

One more thought-stopping technique that we would like to pass on here. This one is called "thought contracting" because you're going to be making a contract with yourself. When you begin to have an obsession, especially if you have one at a particularly bad time (when you have to concentrate on class, when someone else is talking to you, etc.), tell yourself this: "I can't have this thought now, but I'll have it in 5 minutes." Then in 5 minutes, take time out to really experience the obsession - do it on purpose. If you're going to make a contract with your brain to delay the thought, then you have to keep your end of the bargain. There are two advantages to this technique. First, by delaying and then having the thought, your brain will learn that you will honor this contract, and will be willing to let you start lengthening the delay, say to 10 minutes, then 20, then 40, etc. Always remember to have the obsession at the time you mentally agreed upon. The second advantage is that, by having obsessions on demand, you will learn that you do have some control over them, and increasing this control will lead to decreasing their power over you.