OCD and “Passengers on the Bus”

vignetteThis week I am writing about a game I played with a young client who has quite severe OCD.  We are working on getting her ready for exposure treatment at a residential program by playing a role-playing game.

This game is based on “Passengers on the Bus” a great Acceptance and Commitment Therapy video by Joe Oliver, based on a metaphor by Russ Harris.   Let’s say that the client’s name is Amy and she has OCD about getting sick about contamination/germs in the environment.  Her compulsions are washing her hands too often and avoiding touching objects such as doorknobs.

First I asked why Amy is willing to work on her obsessions.   She values her friends and wants to get back to school to see them again (and incidentally, to get more education).  We wrote “friends” in big letters and “education” in small letters on a card and put it on a table at one end of the office.  I role played Amy “driving the bus” so I got up and started “driving” in that direction.

Now Amy, role playing OCD, stepped in.  “What if you get sick?”   “There are germs on doorknobs everywhere and you might die.” It’s too dangerous for you to go to school.” “You should just stay home and not take risks.” “If you touch any doorknobs you have to wash your hands or you will catch a disease.”

The first time around, I fought with “OCD”/Amy.  This is the part that is most fun.  Kids enjoy it when I yell, “Shut up OCD.   I won’t get sick.  It’s not dangerous to go to school.” We went back and forth “fighting” about whether “OCD” was “right”.  Meanwhile, I was not making progress towards my goal value because all my energy was spent fighting “OCD”,  not driving the bus.

The second time around, I gave in.  I said to “OCD”/Amy, “I think you’re right.  It’s just too risky to start touching knobs and if I do have to I should wash my hands really, really, thoroughly.  It’s too hard to take those risks.  I’m better off just staying at home.” I didn’t even start driving towards my goal values.

The third time around, I wouldn’t  engage with the content of what “OCD ” was saying.  I recognized that “she” was there. “I hear  you, OCD.  I know I can’t make you go away.  I am just going to go ahead and focus on getting to my goal. It’s OK, you can go on yelling at me.  Yell all you want.  I am driving this bus, and you are not in control of me. I can still drive to where I want to go.”

We sat down and talk about what worked best.  The first option was too tiring.  I didn’t get very far because I was fighting the content of what “OCD” said.   The second option stopped me from making any progress at all.   The third option let me get to my goal, as long as I allowed  “OCD”  to yell and shout at me, but kept my focus on where I wanted to go.

This role play game was  actually a gentle exposure in its own right, but it incorporated some fun too.  “Amy”  is making progress in learning about OCD, and working towards more difficult exposures she’ll do at the program. She asked to take home the paper with her goal values (friends and education) listed on it so she would remember why she was working on her OCD.

Adults can play this game too, and it can be used for any kind of negative thinking.



OCD and the family

tree peonies by fenceFamily members of people with OCD are frequently puzzled and distressed because they don’t know how to help.

Those who feel most powerless are often the parents or partners of adults who refuse to get treatment.  Their own lives may be severely disrupted.  They may not realize that help is available.  Dr Alec Pollard has created a “Family Recovery” treatment which I use with families.

I begin by asking the family about the symptoms the person who may have OCD is displaying.  (Some people already have a diagnosis of OCD which is known to family members, but others do not.)  Of course I cannot accurately diagnose the person through reports alone, but I can get some idea of what is happening and whether there are any additional acute  concerns (such as severe depression and suicidal statements/gestures).  If there are such concerns, we focus on those first.

Let’s take the example of parents with a son who doesn’t work, contributes no money to the household, and plays video games most of the  day.  He has certain rituals that he insists the family participate in.  For example, everyone may have to change their clothes immediately upon returning home, and all clothes worn outside the home have to be left on an unheated enclosed porch where there is no space to store them.  The son owns a car which he rarely uses, and the parents are making payments and paying the insurance so he can go to an interview if he gets one.

I would ask the parents to list all the effects on their own lives.  In this example, the mother may have stopped having dinner with her friends and going to  her book club, because of the difficulty in keeping any of her clothes looking neat.  She irons an outfit on the front porch every day before work. She is exhausted and sad, and  but believes her son can’t help his behavior and she would be a “bad” mother if she didn’t do what he says.   The father, who works in construction, also participates in the ritual because of the mother’s urging.  He is extremely angry and believes that his son could change if he wanted to.  He missed going out to the movies with his wife, and he’s angry that he can’t replace his old truck, because they have been covering their son’s car payments and insurance since his unemployment ran out.  The parents’ marriage, which used to be good, is severely strained by their arguing about what to do about their son. ( In this example, it is the mother who is more insistent on accommodating, but it is often the father instead.)

I ask each parent to list their accommodations – both the things they do and the things they have given up doing because of their son’s OCD.  Both have given up social activities and managing their own clothes.  The father has given up getting the truck he needs.

Next we make a plan for the parents to recover their own lives.  It’s important to note that at this point they are NOT trying to force their son to get treatment.  They are simply reclaiming their own freedom of action.  Both parents must agree on the plan.  They don’t talk to their son about it or implement any changes until they have worked out the details and agreed on a time frame.

The  plan for this family has to be something the parents can agree on.   Education for the parents may be necessary to help them avoid expecting too little and taking on their son’s  responsibilities, or expecting too much – that he could just chose to stop having the problem.  The plan may include wearing whatever clothing they chose, and keeping it where they choose.  They might agree to stop paying for the car and insurance, and let their son take the responsibility of deciding whether to sell the car or let it be repossessed.

Once the plan is in place the parents set up  a time with their son to discuss the it.  They present it as something they are doing for themselves and try to keep the tone as light as possible.  They don’t talk about their son getting into treatment.  They set a time frame of several days or more so their son has an opportunity to get used to the idea of the change before it actually happens.

It’s important before the meeting to address potential “sabotage behaviors”.  Their son may threaten to hurt himself, them, or their belongings.  These issues have to be thought about beforehand.  If he makes comments that imply self-harm they should contact the police and request that they do a “safety check”.  Similarly, if he threatens them or damages property they should call the police.  In both cases, they can stress that their son has a mental illness and needs to be assessed at the emergency room.   This is usually the hardest thing for the parents to do.  It may help them to talk about whether it is helping their son for them to accommodate his illness.  They need to agree on what to do about sabotage behaviors before the meeting.

Once the parents stop accommodating and get their own lives back , we can begin to talk about how they can make changes that may directly motivate their son to get into treatment, such as using incentives.  However, they also may need to think about how to plan to  help their son if he continues to refuse any treatment.  OCD is a qualifying diagnosis for Department of Mental Health services in Massachusetts.  He may need to apply for Social Security or SSDI (which would require that he be assessed).  The National Association for the Mentally Ill has chapter meeting that offer support for parents with adult children with chronic mental illness.

Obsessive Compulsive Disorder Treatment with ERP

Many, probably most, clients who have OCD are initially ambivalent about getting treatment.  If they have heard about Exposure and Response Prevention, the “gold standard” treatment for OCD, they know that more than talking is involved.  What’s “response prevention”?  It sounds pretty scary.

To understand ERP,  it’s important to learn to distinguish between obsessions and compulsions.  An obsession is what makes the client afraid.  Is he sure he turned off the stove?  If he leaves it on, there could be a fire.  A compulsion is what makes the client feel better.  He will go and check.

This sounds pretty simple so far.  Everyone occasionally has to check something.  The trouble is that in OCD, the very action that makes the client feel better, ends up making the situation worse.

If you don’t have OCD, you check the stove once, and that’s it.  The person with OCD , however, has to make absolutely sure the the house and everyone in it is safe.  Could there be a small possibility that he didn’t look at the switch properly?  He checks again…and again…  The problem is that there is no way to be 100% certain of anything.  The checking behavior is reinforced because he feels better for a few minutes after he checks, but the obsession keeps coming back.

OCD can show up in ways that are less obvious to other people.  The client can’t be 100% sure that she really loves and wants to stay with her partner.  She obsesses about it and has mental compulsions, going over her thoughts about him or her over and over again.  She may worry about getting cancer if she has to visit a hospital or doctor’s office.  If she thinks about a town where she had a bad experience when she is in a different town, both towns may become “contaminated” with negative feelings and she may have to avoid them and all the people that remind her of them.

Some clients have “just so” OCD.  They have to keep vacuuming or organizing until they “feel right”. Work may have to be done on a rigid schedule with no flexibility.  Nothing can be out of place.  Sometimes people without OCD joke about wanting to have a “little bit” of it.  But there is nothing funny about wasting your life on meaningless rituals.

Other  OCD clients are afraid of discussing their obsessive thoughts with anyone.   In OCD,  the brain can get “stuck” on horrific thoughts, such as harming a baby or molesting a child.  The client with OCD is afraid that, because he had the thought that it would be physically possible for him to do such a thing, it means that he really”wants to”.  This is not true.  His brain is equating thoughts and images with actions.  We don’t have control over what thoughts and images pop into our minds, and frantic attempts to make repellent ones go away don’t work.

Exposure and Response Prevention is the effective treatment for OCD.  It is done gradually and collaboratively, with lots of support.  The therapist starts with education, and makes a list of situations the client fears (obsessions), from the easiest to the hardest.  Exposure treatment is facing the obsession, putting yourself in the feared situation.  Response Prevention is refraining from doing any compulsions (mental or physical rituals, or compulsive avoidance).  The client starts with an easier exposure and prevents herself from doing any compulsions during “exposure time”.   During the session, the client may write a story about what she fears or practice touching “contaminated” objects such as doorknobs or faucets.   She will have “homework”.  For example, she might read the anxiety-producing story she wrote during the session every day , or write down that she wishes someone she loves would get hurt, or clean the house in the “wrong” way.  The therapist and client have to work together to define the obsessions precisely so the exposure “fits” and is effective.  Also, it’s important to make the exposure easy enough so that the client can succeed in preventing compulsions.

During “exposure time” the client refrains from distracting herself and just “sits with” the anxiety  without doing any compulsions.  Once exposure time is over she can distract herself by doing other things.  If the client isn’t able to give up compulsions altogether, she is allowed to do them the rest of the time, but not during the planned exposure.  Avoiding feared situations (such as driving if the client fears he may accidentally run over someone) is a compulsion, and the exposure would be to start driving again.

There are two theories about how ERP works.  The client learns that she can tolerate the anxiety of the exposure.  Also, she gets used to the anxiety the situation provokes, and it goes down during the session and with repeated exposure practice.

I offer Exposure and Response Prevention treatment (ERP) and also Acceptance and Commitment therapy, a mindfulness-based treatment that helps clients “defuse” from their thoughts.  ACT complements ERP, and is used with it in treatment centers such as the McLean OCD Institute.



Trichotillomania Treatment with COMB

cognitive behavioral therapy worcester cbt

Therapy for Body Focused Repetitive Behaviors (like Trich. and skin picking)  has changed a lot in the last several years.There is now a new therapy called COMB which helps the therapist and client pinpoint which strategies to manage  pulling and picking are likely to help the most.   COMB was developed by Dr Charles Mansueto and colleagues.

Today I’m writing about how I might approach treatment with a child or teen. However,  if you are interested in treatment for adults, please keep reading, as the same general principles apply.

I encourage parents to buy  Ruth Golomb and Sherrie Vavricheck ‘s book,  “The Hair Pulling Habit and You,” a COMB workbook for kids and adolescents.

First, I help the child make a list of all the places and situations (such as when in the bathroom, when sitting on the couch, when doing homework, etc.) in which he or she picks or pulls. Then we figure out a strategy to use in each of these situations.

I tell kids that some people have a greater need to “fiddle” than others.  It’s important to recognize this and cope with it rather than fight with it.  We can figure out good strategies to help cope with the need to “fiddle”.   I explain that an easy way to remember the different strategies is to think of a “Fiddling Sheep.” Each letter stands for a type of strategy.

S stands for “sensory.”  Many people like to “fiddle” with smooth stones, koosh balls, brushes, pipe cleaners,  etc.  I suggest additional “fiddles” such as knotted dental floss.    The Trichotillomania Learning Center has a store on its website and sells many attractive “fiddles”.  The kid will keep “fiddles” on hand, for example, when he is doing his homework, and use them to cope with the urge to pull.   Some of the TLC “fiddles” are cleverly disguised as “regular” pens, erasers, etc, so that they can be used in class without attracting attention.

H stands for “hard”.  Many kids are helped by strategies that make it harder to pull or pick.  Putting Vaseline on eyelashes or wearing a hat can help, for example.  Any kid can wear a hat in bed or at home, and some kids get permission to wear a hat in school.  A kid who has to take his hat off before pulling is much less likely to pull.

E stands for “environment”. There are ways to change the child’s environment to lower the triggers for pulling. For example, dimming the lights in the bathroom means the child can’t see stray hairs.

E stands for “emotions”.  Kids with BRFBs, like adults, tend to pick more when they are under stress.  Learning better ways to cope is an important strategy for stopping picking.   Many kids, and particularly adolescents, feel terrible after they pull, and it’s important to learn to cope with “lapses” and go on with the treatment program.

P stands for “perfectionism”.  Kids with BFRBs sometimes think that anything  less than a perfect grade or dance performance or game is a disaster.  Some of them are perfectionists about their bodies, thinking that it’s terrible  to have any unevenness in their hair or skin.  This kind of thinking encourages pulling and picking.   We work on challenging their perfectionist thoughts and replacing them with more realistic ones.

I help parents set up a chart and teach them how to reward their child, not for not picking, but for using the strategies.  (Here I am teaching the parents not be perfectionists.  It’s distressing to see your child suffer.  Parents and kids both benefit by seeing the effort, not the result, as the thing to reward.) I also encourage adults to reward themselves for not pulling.

Kids and adults can be successfully treated for BFRBs, but they will almost certainly  have lapses.  I believe that therapy has succeeded when a kid can have a pulling episode, manage the resulting distress, and start using the strategies again.  This is what helps in the long run.

Attention Deficit Disorder and Internet/Screen Addiction.

Internet Addiction, Executive Functioning and ADHD
Executive Functioning, ADHD and Internet/screen addiction

Internet Addiction is a growing problem in our society, and people with attention and other “executive functioning” difficulties may be particularly vulnerable.

These are some of the brain functions which we call “Executive Functioning”:


Working memory (keeping what you need to remember in mind)

Organization skills

Controlling impulses to act (also controlling  impulsive “jumping to conclusions” )

Getting going on tasks you may not want to start

Monitoring how well you are doing on a task and using the information to change your strategy

Prioritizing your tasks and making plans

Controlling your emotions (not overreacting)

Flexibility (the ability to change your plan in response to a new situation)

You do not have to have Attention Deficit Disorder to have EF problems.  For example, a person with poor working memory and organizational skills would not necessarily meet the diagnostic criteria for ADD or ADHD. But he or she could still benefit from learning skills to compensate for the EF impairment.  For the client with ADD/ADHD, medication is the primary treatment, but most people with ADD will still need help in compensating for EF issues.

EF can improve as the brain matures.  However, our modern world demands a much higher level of EF skills than was historically necessary for most people.  We have much more physical “stuff” and much more information that we need to organize than people did in the past.  We are also bombarded with competing demands for our attention, many of which have been designed specifically to “trap” us into acting according to the best interests of someone else, rather than ourselves. Escape and avoidance are available at the click of a mouse.  This is a problem for a very large number of people without EF problems, but it is particularly likely to be a trap for people ADD/ADHD.

If you have problems with attention or getting going on tasks, you will find it extra difficult to avoid being drawn in by fascinating but irrelevant material in the Internet.  (Porn is a subset of this, but a big issue in itself.) Because the distracting Internet material (including social media) is gratifying, its use can easily develop into a behavioral addiction.  So now the person with ADD has much more difficulty getting anything done.  Anxiety and depression can easily develop (if they were not present already).

When I treat a client like this, I work on the addictive behavior, the anxiety and the depression at the same time as the attention/EF problems.  We identify triggers for Internet abuse, and I teach coping skills for the unpleasant feelings that accompany getting “sober” from any addiction.   I teach the client to “avoid avoidance” – to avoid the escapism that can easily be triggered when he or she is working on the Internet, and which reinforces anxiety and depression

There is a specific CBT treatment for ADD/ADHD in adults  in the “Treatments that Work” series, “Mastering your Adult Attention Deficit Disorder” by Safren and others.   The client workbook is a great buy for anyone with EF issues. (It is available on Amazon.  Be sure to get the workbook, not the “Therapist Guide”.) The workbook teaches specific skills to compensate for EF difficulties, in a clear, organized way that can be adapted to your own needs.  Having these skills can help people who are struggling with Internet abuse.

“Mastering Your Adult ADHD”, by Steven Safren, Susan Sprich, and Carol Missing,”Treatments that Work” series, Oxford University Press.








ADHD- How to help your kid.

Exectuive Functioning - How you can help your kids.
Exectuive Functioning – How you can help your kids.

This week we talking about managing the return to school.

Today’s schools demand a high level of self-management from kids.  When children and teens  have difficulty with ADHD or  “executive functioning” – managing their emotions, attention, and time, learning to set priorities, remember, start tasks and persist with them – it can be very stressful for the whole family.

In “Smart but Scattered” by Peg Dawson Ed. D.  and Richard Guare, PhD, there’s a list of questions about “executive functioning” for parents to fill out, to help them understand  their own EF  strengths and weaknesses.  I was interested in this because I know that EF weaknesses made my life more difficult both in my birth family and with my own kids. I filled out the questionnaire, and the answers matched my experience.

I am one of those people who have weaker organizational skills and “working memory” (what helps us to remember what we need to do today).  Over the years, I’ve developed coping skills for this.  I have no paper records in my practice because it’s hard for me to keep paper organized.  (On the computer it’s a breeze for me to organize lots of information. ) I also write down my plans and all the things that occur to me while I’m doing something else.  I keep a pad and a pen by my bed in case I remember something when I wake in the night, and I’ve got a special file on my computer where I keep a “to do” list.  If I don’t do this, I’ll forget something.

As a parent, I found  the endless flow of permission slips and pieces of paper that needed to be kept  a real challenge.  Relatives often have similar difficulties,  and my kids were not good at organizing and remembering either.  Like every parent who wants to help their kid but isn’t good at what’s required, I found the situation very frustrating.

I also think my own mother was frustrated by my poor working memory. Since she was excellent at organizing and remembering, so she found it very difficult to be patient when I repeatedly left my field hockey bag on the bus instead of bringing it home.  Each time this happened, we had to drive several miles to the public bus depot to get it back.

Dawson and Guare have some good suggestions for parents faced with having the same executive functioning weakness as their kids.    Try to look at the funny side rather than getting into struggles.  Work on the problems  together.  You manage to compensate well enough for your weakness to cope with the adult world, and you can help your kid to do it too.   They describe in detail how to work on your own weaknesses at the same time as your child’s.

For parents who have strengths in the areas where their kids are weak, Dawson and Guare also have good suggestions.  Try to get your child to accept your help.  Find creative ways to help him or her get organized.  Also, consider that your child may have strengths that you lack.  This will help you feel more patient and hopeful rather than irritated and frustrated.

I highly recommend Dawson and Guare’s book for parents.

Peg Dawson and Richard Guard, “Smart but Scattered, Boost any Child’s Ability to get Organized, resist Impulses, stay Focused, use Time wisely, Plan ahead, Follow through on tasks, Learn from mistakes, stay in Control of emotions, Solve problems independently, and be Resourceful.”

Guildford Press, 2009.


Trichotillomania Symptoms


Hair Pulling and Skin Picking, part 1.
Hair Pulling and Skin Picking, part 1.


People with Body Focused Repetitive Behaviors like trichotillomania (hair pulling) or dermatillomania (skin picking) are often afraid that others will think they are “weird”. They feel ashamed and keep the behavior a secret.

The Trichotillomania Learning Center is breaking silence about these problems.  Their website, www.bfrb.org , is full of helpful information.  It’s aimed at bringing hope to those suffering from the disorders, and training to mental health professionals.

In the past, these problems were often regarded as “just habits”, not a significant source of distress or life impairment.  Alternatively, some professionals saw them as indications of “deeper” psychological problems. BFRBs were poorly researched until quite recently.  We don’t even know how many people will experience them. One study found that 1.5 % of male and 3.6 percent of female college students suffer from trichotillomania, and the numbers may be even higher for other BFRBs.  More research is needed on these disorders.

Surveys indicate that many people with BFRBs have never  been diagnosed.  “Talk therapy” is not effective for BFRBs.   It’s true that BFRBs, like anxiety, are problems that good treatment teaches people to manage rather than overcome forever.  But being able to manage a problem feels so much better than being overwhelmed by it!

In this first episode, we will be looking at possible causes for BFRBs.  Treatment will be discussed in a later blog.

It is not true that BFRBs are just symptoms related to inner conflicts.  Many factors play a role in the development of a BFRB.   The visible results of the BFRB are themselves a significant stressor.

Studies of twins indicate that there’s a genetic basis to BFRBs.  Twins who developed from the same embryo are much more likely to both have a BFRB than twins who developed from different embryos.  DNA testing is being done on people with BFRBs.

It’s interesting that animals, including dogs, cats, horses and birds, can develop behaviors that mimic BFRBs.  For example, a bird moved to a different cage may experience stress and beginning pulling out its feathers.

BFRBs may be linked to imbalances in some brain chemicals, such as serotonin (which can be regulated by antidepressants) or natural opiates that originate within the body.

There’s some evidence that people with BFRBs have biological difficulties in regulating their degree of arousal.  They may find it very difficult be in boring, unstimulating situations such as driving, and “automatically” pull or pick, without even being aware of doing it.  The pulling stimulates the fingertips, which have lots of nerve endings.    People with BFRBs may also consciously pull or pick when overstimulated by stress, to calm themselves.  This is called “focused” picking.  Most people with BRFBs do both types of picking, though one may predominate.

Many people with BFRBs find that the pulling or picking is pleasurable and reduces tension they felt previously  However, feelings of shame and regret often arise once the picking is over.

Another important aspect of BFRBs  is the association of the behavior with certain places and activities.  A teen who pulls while doing his homework at his desk may come to associate the desk with pulling, so that sitting down there becomes a powerful “trigger”.

One treatment for BFRBs that focuses on changing behavior is called “Habit Reversal Training.”  However, Drs Charles Mansueto and Fred Penzel, and Ruth Golumb, have developed a more comprehensive behavioral treatment,  COMB.    It helps people make changes in different areas that contribute to and maintain the problem – ,managing physical sensations, thoughts and  emotions and the physical environment. This will be discussed next time.




Obsessive Compulsive Disorder Treatment – “Just So” OCD

ACT and OCD (again)


Recently, I’ve been reading a very interesting discussion on one of the professional listservs I’ve joined.  One writer cited the concept that the “core belief” of people with OCD is that they are “bad people”.  This is true of many clients, I believe, but not all.

We know that OCD attaches itself to areas of life which are particularly important to the client.  Years ago I saw a woman who was obsessed with reading each page of a text “properly” (ie. paying attention to every word, and also the page number).  As a result of being compulsive about this, she read very slowly.  She wanted to become an academic, but could only take one course at a time.

I wish that I could go back and ask my client  whether she would describe skimming  as a moral issue or not.    I actually believe that was not the problem.   The real issue was uncertainty about whether she had done the reading “completely”. This is a form of “just so” OCD.

“Just so” OCD is driven by an intense discomfort with situations that are not “ordered” correctly.  This is the OCD of popular culture.  “He’s OCD about having his drawers neat.”  It can indeed apply to physical neatness, order and symmetry – conventional norms.   But it can also create its own “rules”.

“Just so” OCD afflicted another of my clients, a man who could not eat meals until various household tasks were done in the “correct” order.  This affected his ability to eat regular meals, and caused him to gain weight, because he tended to eat one very large meal a day.   He felt really uncomfortable if he “disobeyed” his OCD-driven expectations about what he should do first.  The “rules” that these followed were created by his OCD.

Some people have to continue to perform a compulsion until they achieve the “just so” feeling that allows them to relax.  My client with the compulsive ordering of household tasks was like that.  Uncertainty briefly fades away.  Of course, the problem with this is that OCD will create more anxious thoughts – ‘Am I certain I cleaned that properly?’ – and then the compulsions will begin again. Once you begin having to vacuum the bedroom before you can eat, you may soon  have to clean the shower too.

The core belief that one is a “bad” person is certainly at the root of many kinds of intrusive thoughts. …..  ‘I had the thought I could push him in front of the train, so I must “really” want to do it’ ……..OCD clients get filled with horror at having the kind of “crazy” thought that research shows that everyone experiences.  The thought is seen as equivalent to the action, and the client can’t let go of the fear that having the thought means he or she is bad.  In fact it means that the client has a brain that easily gets “stuck” on thoughts about actions that break his or her moral code, whereas other people don’t notice them or shrug them off.

I don’t think the people with “just so” OCD necessarily see themselves as bad people.  However, OCD can take different forms at different times.  My client with the reading problem got into a relationship and became obsessed with the fear that she would hurt her boyfriend.

There is so much to learn about OCD!  The IOCDF also sponsors a series of talks for clients and providers at UMass Medical Center in Worcester, at McLean Hospital in Worcester, and in Northampton.  After the talk, there is a peer-led support group for adults with OCD, and another or family members.

www.ocdmassachusetts.org – Go to local resources, then Our Programs, then Lecture Series.




Acceptance and Commitment Therapy and being mindful: Just looking


This week I am thinking about Acceptance and Commitment Therapy and being present.

My favorite way of not being present is reading.  Of course, I have been incredibly educated, enriched and inspired by what I have read.  It’s hard for me to imagine who I would have become without access to books.  Nonetheless, it’s clear that sometimes I am simply “not there” because I am absorbed elsewhere.  My husband likes to watch baseball .  I can enjoy an interesting game, but when I am really tired I will “tune out” everything and everyone and just read (lying down on the rug in front of the fireplace in winter).  I know that my husband sometimes “misses” me when I do this, and I am trying to be more aware.  I see the problem as a kind of old-fashioned version of screen addiction,  based on wanting to escape into the story  rather than being “hooked” by social media or video games.  I know this problem has existed since I learned to read.

For July 4th, I visited my daughter who now lives on a farm.  It was the first time I ever stayed at the farm.  It was also the first time I essentially didn’t read for many, many years (since I was 7 or 8?).

Part of the reason was that I was so busy with my family.   But the main reason was that I loved looking at the view.

My daughter’s house is tucked into a hill and looks down over a dairy farm in the valley.  There is another house at the end of the driveway, but apart from that you can’t see anything else but nature/farm  from the front porch.  I could sit there all day.

The cows eat grass as well as hay.    In the morning after they’ve been milked, they head down the path towards the fields where they graze.  In the late afternoon, they come back in again to be milked, and then go back to graze again.  I imagine that they stay out in the field at night and return in the early morning, or perhaps they come back to the barn after it gets dark. – I didn’t get up early enough to learn about that.  The rhythm soothed me.

I loved sitting on the porch and just looking.  At night there were fireflies, which I had remembered from when I lived in the country in Massachusetts, but hadn’t seen in years.  Weather systems could be seen approaching from across the valley. Sometimes I could see where it was raining and watched as the rain came towards us.

Just watching is a form of meditation.  There is so much to see.  I didn’t want to go in and read, or bring my book or Kindle outside.  It felt right just being there, not thinking about anything.    I felt in tune with the changes as the day went by, because I sat on the porch at different times.

Now I’m back I’m trying to remember this.  When I eat breakfast in the garden I don’t read, I just eat and watch the birds.  I can read when the snow is on the ground!  Chickadees and woodpeckers and purple wrens and cardinals are not so easy to watch then.  If I don’t look now I will miss my plants and flowers and the sound of the fountain in the pond.   Habit alone makes it appear necessary to read at breakfast.

Happy looking this summer.


CBT and Anger Management, part 1



CBT and Anger Management

This week we will look at “standard” CBT approaches to anger management problems.  In the next blog, we’ll add to this by talking about the mindfulness-based/Acceptance and Commitment Therapy approach also.

People who have difficulty in managing anger can damage relationships with loved ones, lose friendships and career opportunities, even if they “only” speak angrily or act passive-aggressively  rather than do physical harm to others, themselves, or property.

As we all know, it is difficult when you are angry to take time to examine thoughts.    All of us have had the experience of saying something that was ill-advised or unkind,  developing an irritable mood, or withdrawing when someone “makes” us angry.  The first step in dealing with anger is to take some “space” so we can think before speaking or acting.

The proverbial “deep breath” (using “belly breathing”, rather than breathing lightly into the chest)  can really help in the initial stages.  It’s a direct way to “tell” your body it’s OK to be calm.  Even sitting down rather than standing can make a distance.  (Picture someone yelling sitting down. – It doesn’t fit.) Sometimes it’s also necessary to leave the situation for a while in order to calm down.

Next, it’s important to  consider the kind of thoughts that provoke anger:

1. Excessive expectations of others

If someone is  driving too slowly in the fast lane,  I might be late, or to have to change lanes a couples of times.  Do I have believe that other people  “should” never do this?  What about people who dress in a way I consider inappropriate or speak to a third party in a way I consider disrespectful?  If a person does not measure up to my personal standards, is it really my business?  Is it advisable or necessary for me  to “correct” the person’s behavior or ruminate about how “bad” the person is?

When someone believes that it is his or her job to “fix” other people by pointing out their errors, it is a setup for becoming and staying angry.  Of course, we should all speak up about certain situations, but some angry people try and “fix” everything.  Since we have no control over many annoying situations, getting angry about them achieves nothing and results in chronic irritability.

2. Personalizing

Is the person who “made” me angry doing something “on purpose” to make me mad?  Many times we think other people are focused on us when they are absorbed in their own concerns.  Their actions relate to their own lives, not ours.  Angry people often have “cognitive impulsivity”.  This means that they jump to conclusions about the meaning of situations without taking time to think it through.  This misinterpretation can lead to angry behavior.

Unfortunately, excessive personalizing really can  encourage other people to try to provoke you.   Kids and teens in particular will try to “set off” a kid who “loses it” too easily, and some adults will do it too.  I tell clients that being too easily provoked is like having a target on your chest.  You are giving up your own power over your life and giving it to others to hurt you.  If you can learn to be less reactive, the behavior will stop.  If you are a parent, it’s particularly important  to learn not to overreact.  If you can be provoked too easily, your child will not only be afraid of you but also lose respect for you.

So far we’ve been thinking about the way thoughts affect angry feelings and behavior in “real time”.    Just learning to take some time to think things through can really help people who get angry fast but can calm down quickly.  Let’s consider now people who are chronically angry, hold grudges, and can’t let the anger go.

This problem is caused by “rumination” – going over and over the situation in your mind after it’s over.  This is not the same as problem-solving.   If “venting” to other people or thinking the situation through repeatedly  is helping you work out potential action plans,  it’s useful.    If you get stuck in ruminating and complaining about how bad other people are, you’re likely to  hold grudges, “freeze” your loved ones and friends out of your life, and damage your physical health.  This chronic hostility makes it difficult for you to acknowledge any share in responsibility.  You may become “passive aggressive”, denying that you are angry but doing things to “get back at’ other people.

Angry rumination like this is actually a way of avoiding having to “sit with” the physical and mental discomfort of really feeling the anger.  You escape into self-righteous and possibly vengeful brooding instead.

Mindfulness-based approaches are most useful in treating this problem.  They also help anyone who is faced with an unchangeable, painful situation, which can lead to chronic anger and depression.  We will talk about them in the next blog.