Five years ago, Seth Gillihan, PhD, wrote a guest post for my blog. Since that time, we have co-authored Overcoming OCD: A Journey to Recovery , and Seth’s own book, Retrain Your Brain: Cognitive Behavioral Therapy in 7 Weeks: A Workbook for Managing Depression and Anxiety, has been published. Seth continues to work tirelessly in his private practice to help people overcome their OCD. He also has his own blog. His popular guest post resonated with many people, and I think it’s more than worthwhile to publish it once again:
Some of my colleagues and I recently wrote an article about common therapist mistakes in exposure and response prevention (ERP) therapy for OCD. I wanted to highlight one of the sections of that paper that may be helpful to individuals whose compulsions are primarily mental. Mental compulsions typically involve words, phrases, prayers, and so forth that the person says silently in order to prevent a feared outcome, or to reduce the anxiety that the obsession causes (see full article for a list of common mental compulsions). For example, a person might have religious obsessions and may fear that her children will become sick if she has blasphemous thoughts. In response to any blasphemous thoughts or images that come to mind she will repeat to herself a memorized prayer about the greatness of God with requests for protection for her children.
The first step in treating OCD that involves primarily mental rituals is to recognize the familiar cycle of obsessions and compulsions. Just like with observable rituals, mental rituals maintain OCD by providing temporary relief from the OCD-related distress. Some clinicians may fail to identify covert/mental rituals, and people with OCD similarly may have a hard time distinguishing between an obsession and a mental compulsion. When thoughts are coming quickly one after another, some causing distress and some intended to relieve that distress, it can feel like a jumbled mess and the compulsions can be hard to identify. For this reason OCD with mostly or only mental rituals is often mistakenly labeled “Pure Obsessional” (or “Pure-O”) OCD.
The way to tell a mental compulsion from an obsessive thought is to ask what the function of the mental act is: Obsessions increase anxiety whereas mental compulsions are intended to decrease anxiety.
Once a person knows what his or her mental rituals are, it is crucial that the person eliminate them in order to recover from OCD. During ERP the individual must avoid doing mental rituals during exposure—for example, saying ritualized mental prayers to neutralize the fear of harm that comes from doing the exposures. These kinds of private rituals undermine the exposures and can prevent the person from getting better.
As discussed on an earlier post, ERP for mental rituals requires one to do the opposite of the rituals and allow oneself to have the distressing thoughts like “I’m a devil worshiper,” without any mental rituals to counteract these thoughts. Easier said than done! A lot of the difficulty, of course, comes from the almost automatic nature of the mental rituals; people with OCD often say they do a mental ritual even when they’re trying not to. For this reason the ERP therapist and person with OCD will need to work closely and creatively together to find ways to block the mental rituals. One solution is for the person with OCD to read out loud material that provokes obsessions (either in vivo or imaginal exposure—see sections 3 and 6 of the article for descriptions of these two techniques) so that the mind is not free to perform mental compulsions. It can also be helpful to say exposure statements to prevent mental compulsions, such as saying “I’m friends with the devil” instead of engaging in a ritualized prayer. Exposure statements should also be used if the person realizes he or she performed a mental ritual—what is often called “spoiling” the ritual.
A final point that we highlight in the article is that it’s usually counterproductive to tell oneself “that’s just my OCD” and similar statements when experiencing an obsession. These kinds of statements play OCD’s game of looking for certainty and trying to find a short-term fix to make obsessions less upsetting. As such, these responses to obsessions often become a ritual, another way to neutralize the anxiety and uncertainty that the obsessions cause. A more effective long-term solution is to answer obsessions with exposure statements that recognize uncertainty: “Maybe I did sell my soul to the devil”; “God might punish me for having that thought.” While I’ve focused here on religious obsessions as an example, these principles apply to any obsessional content.
The bottom line of this discussion is that, contrary to what some people with OCD believe or have heard, ERP can successfully address mental rituals. Armed with knowledge about how to recognize mental compulsions, determination to conquer them, and often with the help of a skilled therapist, individuals with mental compulsions can live more enjoyable and fulfilling lives.