The Guide above is provided entirely for free to newsletter subscribers.
One of my first questions to a professor in my earliest IOCDF BTTI (Exposure Therapy training) at Massachusetts General Hospital was, “What happens if someone actually gets sick after a contamination exposure?” I haven’t forgotten the simplicity of the answer that went something like this: “People get sick all the time. Yes, that might create some additional hesitancy to face exposures at first, but you have an incredible opportunity for learning.” Life involves not only facing bad things that don't happen, but also bad things that do.
Exposure Therapy involves the systematic confrontation of fearful triggers while reducing and eliminating fearful, pathological responses. In the end, it can relieve a lot of suffering.
During this global pandemic of COVID-19, people actually are getting sick. One might not think the principles of exposure therapy would apply (i.e., "Don't you do exposure therapy for risks that don't happen?"). Quite the contrary. I believe exposure therapy provides one of the best evidence-based ways forward, helping us stand up to fear we need to squarely face. So today, whether you have a disorder or not, there is an opportunity for learning and growth in the face of COVID-19.
This guide, "Thriving Mental Health Alongside COVID-19," is dedicated to my clients and the IOCDF and provides a thorough summary of the main steps of Exposure Therapy with me, with key tips for general mental health. May you be enriched by this!
Whether you have a mental disorder or not, there is an opportunity for learning and growth in the face of COVID-19 (SARS-CoV-2). Now, more than ever, we need stable footing to stand on. People go to every extreme. You don't have to. Mental health is about being grounded in reality, insomuch as we can grasp it.
Getting sick will happen. Yes, people die. Relationships break up and fail. Businesses go under. We might get it wrong. However...many people can experience health. Some people live with purpose and to the full (which is not the same as perfect). Relationships can be incredible. Businesses can thrive. We can get things right.
When I utilize the method of Exposure Therapy in counseling (a subset of Behavioral and Cognitive Behavioral Therapy), it involves the systematic confrontation of fearful triggers while reducing and eliminating fearful, pathological responses. It is Gold Standard treatment for OCD & Phobias, and is a first line treatment for all Anxiety Disorders and PTSD. What we think happens is that relearning occurs, which for most increases confidence and decreases disruption in life when they follow the treatment. Exposure, then, gives us two opportunities:
2. To learn we can face it anyway.
Its principles connect us to some of the best of life: face the thing you have reason to face; gain the opportunity to live more fully.
This guide is a very brief summary of the main points of the exposure therapy process with me, particularly with clients who have OCD and Anxiety. Many of my clients actually are faring better in this crisis than people I have talked to and seen in the general public- and why wouldn't they?! They've been training and learning- and now it's game-time.
Click "Read More" for a Summary
Exposure and Response Prevention (ERP), the gold standard treatment for OCD, can be fairly straightforward once understood. However, certain nuances are crucial for facilitating learning, growth, and maximal fear disconfirmation (fancy terms for successfully overcoming fearful responses). Here are 10 tips- click on the picture for a downloadable version:
Adapted from: Abramowitz, J. S., & Jacoby, R. J. (2015). Obsessive-compulsive disorder in adults. Boston, MA: Hogrefe Publishing.
This post is intended for Christians looking to deepen their faith and mental health and may not apply to my entire reader base.
I am honored to be surrounded by incredible people who exhibit incredible strength and faith in the most trying circumstances. These past few weeks as the Coronavirus has led to increased fears, panic, product hoarding, and expressed racism, I have seen the stellar example of many clients and friends wading these uncertain waters with confidence, skill, and calm.
Many of you know that treating OCD and Anxiety Disorders is how I spend most of my time clinically. Despite the fact that the 'neurotypical' person may think those with disorders are probably “going crazy” right now with the Coronavirus (and it’s definitely been really hard for many), I have found in my practice much the opposite. I am observing right now during the Coronavirus pandemic how those who have trained themselves to persevere through difficult stressors and triggers- with intentional acceptance of uncertainty, mindfulness rather than obsession, and valued action rather than compulsion- are revealing how beneficial the training of the mind and heart is. I have personally experienced more frantic, panic-induced efforts by folks I’ve come in contact with outside therapy than inside my office. I’ve also seen several of my Christian clients reveal an incredibly deep faith that inspires me (even if they suffer with worry and anxiety).
For those of us as Christians, we can rely on awesome skills we develop in therapy, and it also needs to go deeper than skills. Here are some questions to help you consider the truth we stand on:
Are we walking by faith, not by sight?
“So we are always of good courage. We know that while we are at home in the body we are away from the Lord, for we walk by faith, not by sight” (2 Corinthians 5:7, ESV).
Do we believe nothing- nothing- can separate us from the love of God?
“For I am sure that neither death nor life, nor angels nor rulers, nor things present nor things to come, nor powers, nor height nor depth, nor anything else in all creation, will be able to separate us from the love of God in Christ Jesus our Lord” (Romans 8:38-39).
Do we practice mindfulness in what's true?
“Finally, brothers [and sisters], whatever is true, whatever is honorable, whatever is right, whatever is pure, whatever is lovely, whatever is admirable—if anything is excellent or praiseworthy—think on these things. Whatever you have learned or received or heard from me, or seen in me, put into practice. And the God of peace will be with you” (Philippians 4:8-9).
Are we loving our neighbor (which is everyone- see Luke 10:25-37)? Considering others’ needs?
“Each of you should look not only to your own interests, but also to the interests of others” (Philippians 2:4).
I hope you are encouraged- as I have been by others’ faith today- in where our focus as believers is to be. Faith. Hope. Love. The greatest is love.
Justin K. Hughes
If you have a child, significant other, or friend who has OCD, you likely know the suffering it can create. Or maybe you don’t; that’s okay. The unfortunate reality for most clients once they appear in my office is that OCD has culminated in tremendous levels of stress and disability. 14-17 years from the onset of OCD is the average needed to obtain evidence-based treatment. By this time, OCD is typically well-developed. Sometimes, it can function under the level of awareness, even when severe. Family members often feel guilty that they missed it for so many years. You are not alone. This article presumes basic knowledge of OCD, so if you are brand new to the topic, I recommend a primer, such as the following on my OCD Resources page: Intro brochure, ERP for OCD Presentation, and the IOCDF’s “What You Need to Know About OCD”
OCD is an extremely debilitating disorder as a whole, ranking as one of the top ten medical and mental illnesses in the world- right alongside such things as Heart Disease, Major Depression, and COPD, according to the World Health Organization. With 2 out of 3 people reporting severe impairment at some point in their lives (e.g., work, relationships, school), you can count on OCD to create an ever increasing set of problems- without effective treatment. Furthermore, around 90% have at least one comorbid mental disorder, such as Major Depression, Panic Disorder, or a Substance Use Disorder. OCD has a tendency to make sufferers “hostages"- feeling stuck in an ever-narrowing loop of behaviors and/or thoughts that usually seem nonsensical to the person themselves, which tends to drive even more shame. Families and support are collateral damage. It is crucial to identify the threat and connected suffering of OCD in order to fully address its impact- and to have the proper perspective and motivation in getting necessary treatment.
Do Your Research
Attempt to really understand your loved one’s suffering, and understand how to help, howa not to help, and how to stay healthy yourself. Finding effective support and treatment is crucial. You don’t have to have diagnosable OCD to be an incredible advocate. Myself and a majority of my OCD specialist colleague/friends do not have diagnosable OCD. Knowing treatments that are effective helps to stay grounded and focused. In short, a specific subset of CBT (Cognitive Behavioral Therapy) known as ERP (Exposure and Response Prevention) is the Gold Standard in treatment. SSRI medications (and clomipramine, a TCA) are used as the first line psychopharmacological treatments. Supportive psychotherapy is not evidence-based first-line treatment for OCD. You may love a counselor who is very supportive, but if they’re not doing some sort of exposures or behavioral experiments, and there’s not a noted clinical reason why they cannot, consider an OCD specialist, because they are not following clinical practice guidelines. Again, check out my Intro Brochure and ERP for OCD Presentation for more on the research and specifics.
Make the Unseen Seen
Taking OCD seriously involves seeing it- and you may help your loved one see it more clearly through your loving support. When it is beneficial to a client, I almost always recommend involving a supportive loved one at some point in treatment. We would consider it odd or unusual not to involve a family member in many other medical treatments. A major challenge with mental illness is making the unseen seen.
Be Realistic With Expectations
One of the roles I serve is setting expectations. Consider how a coach might observe, teach, encourage, and challenge based on a fitness or performance goal. I know OCD from the inside; you can, too. I want to prevent “injury” from occurring in clients who are overeager and might overwhelm themselves jumping in unrealistically- in order to make progress quicker than their skill and training can support. I’ve seen this occur when clients start with the hardest thing they can imagine doing without the support to do it- they usually get burned out or drop out of treatment altogether if they don’t redirect this focus into systematic, consistent, and sustainable work. Conversely, some sufferers have low motivation or may be depressed. Walking together in the trenches and valleys, I seek to boost their perspective to know there is hope when they don't feel it. You cannot “cure” / overcome core fears in OCD with a single exercise, so pushing a loved one to do something they are terrified of can backfire- reinforcing fear vs. disconfirming it; we need to consistently, systematically face fears by addressing with a strategy and a plan.
Be careful to not underestimate how much of a problem OCD can create- and in turn, how much work and growth is needed to learn to say no to all the compulsions that exist for an individual. When there are additional treatment factors (comorbidity and severity, among others, negatively influence outcomes), they can complicate the learning and growth process . Probably the most common error I see in practice is an underestimation of how much treatment and work is needed to accomplish clients' and families' goals (e.g., in terms of number of sessions, practices at home). We also want to be realistic about outcomes, i.e., getting better. Though the treatments for OCD are highly efficacious for most and can be life-changing in a short amount of time for some, practicing patience in your individual situation is key. No one case is exactly alike. You as a family member can help spell out hope or chaos in expectation-setting- helping your loved one in staying the course without being overly idealistic or nihilistic in their views of getting better.
Facilitate buy-in by reinforcing the principles of what it takes to get better. Validate growth- and always validate the person's value and importance, no matter how much they struggle. Remember to encourage yourself, too!
Support: Don't Accommodate or be Emotionally Explosive
Support needs to strike a balance between being overly-accommodating and overly-emotionally expressive (outbursts, hostility, negativity, etc.). The well-researched terms we use to describe these are Family Accommodation (FA) and Emotional Expression (EE). Break the Cycle!! Don’t Do Compulsions for them (by proxy). Begin (with a plan) to minimize your accommodation. Typically in therapy, I help to incrementally get rid of accommodation altogether without “pulling the rug out” too fast (i.e., in one day). Therapeutically, all client rituals must ideally be terminated to maximize outcomes. Helping a loved one ritualize only feeds the cycle. Don’t Give Reassurance. To do this well, you often need to be involved in the prior steps this article elucidates. It can be tricky to know what is reassurance and what is not. Ask questions of your loved one. If they are not open to sharing, you may have to do your best to set your own boundaries, make an informed guess, and base your limits on your own personal boundaries until they're willing to communicate further. Part of feeding obsessions involves engaging the content of obsessions with logic, emotion, and reactions. The person with OCD must learn to live their goals and values without following the content of obsessions. Be careful not to get pulled in, either through accommodation or emotionality. Offer to go to therapy with your loved one if they are willing. You can also gain much support by doing your own therapy, as well! Part of support may be helping covering costs of therapy. Just to be clear- you get to have your own emotions, whatever they are! But EE refers to when these emotions are expressed in harmful ways.
Make Space for your Own Growth and Boundaries
You are a person with your own thoughts, feelings, life to live and decisions to make. Having healthy boundaries for yourself and family is very important. Helping does not mean loss of your own identity and responsibilities. It is not over-extending, nor is it avoidance of problems. Review the chart above. Your situation is your situation; there is a lot of similarity and variety (homogenous and heterogenous) to stories around OCD. You will likely be encouraged at how others feel similarly; but you also have unique factors that make your story your own- be careful not to compare unnecessarily. For goal and boundary setting, Contingency/Behavioral Contracts might be helpful, especially if you are responsible for someone with OCD (i.e., a child), or if you just need clear guidelines of involvement (how and when to discuss obsessions, financial support, reinforcements and privileges, etc.). Your own support and therapy can help you with you own growth and boundaries. Refer to the IOCDF’s excellent tool to “Find Help.”
You can be a crucial source of ongoing recovery, similar to how a coach or trainer might help. We all need reminders, especially in dealing with a consistent need (exercise, diet, and chronic disorders). You can be part of the team surrounding a sufferer to help them be aware of any new compulsions or problems that may arise. You may want to communicate with them in advance about how to best bring up concerns when they are observed. You can be part of the team that cheers them on and helps with motivation! Remind them of their values and why they want to grow (i.e., to go to school, work, not be controlled by OCD, feel better, enjoy life, help others, grow as a person, etc.).
Practical Tools for You
I often have my parents and significant others complete several documents and incorporate various tools. Each situation will vary, but commonly I use:
If you have made it this far to read this article, you are quite likely a key support of someone who has OCD. It is then very likely that you care and want to make a difference. You rock. Keep up the good work.
Calvocoressi, L., Lewis, B., Harris, M., Trufan, B. S., Goodman, W. K., McDougle, C. J., & Price, L. H. (1995). Family accommodation in obsessive compulsive disorder. American Journal of Psychiatry, 152, 441-443.
Depression and Other Common Mental Disorders: Global Health Estimates. Geneva: World Health Organization; 2017. Licence: CC BY-NC-SA 3.0 IGO.
Gillihan, S. J., Williams, M. T., Malcoun, E., Yadin, E., & Foa, E. B. (2012). Common Pitfalls in Exposure and Response Prevention (EX/RP) for OCD. Journal of obsessive-compulsive and related disorders, 1(4), 251-257.
What You Need To Know About Obsessive Compulsive Disorder. (n.d.). Retrieved February 2, 2020, from https://iocdf.org/wp-content/uploads/2014/10/What- You-Need-To-Know-About-OCD.pdf
An editor for the American Counseling Association reached out to me about OCD from a Specialists' perspective. (I was so proud of them for doing their research with multiple specialists!!). The following are excellent questions that may help inform their ACA magazine article in February 2020. Whether they utilize any of these or not, I hope they are helpful for you as they cover important questions to consider with regard to treatment.
"What presenting issues might bring these clients into counseling?"
"What are some “red flags” for counselors to listen for that might indicate OCD in a client who came in for something else (anxiety, ADHD, etc.)?"
If a counselor begins hearing the exact same things, worded or behaved in similar ways, this is a good indicator to watch out for. Many of my clients are good at exactly quoting themselves on what they've said before. Obsessions are repetitions on a theme; if you get good at catching the theme, you can usually spot an obsession miles away.
At its core, it's not remarkably difficult to identify criteria in OCD (in most straightforward cases) if a counselor brushes up on what they're looking for (dust off that DSM-5!).
Furthermore, if a client isn't improving from certain methods (especially things like Cognitive Restructuring in CBT), this is "Getting Stuck 101" and needs further assessment. Most of my clients have had prior experience with a counselor who had no idea how to treat OCD from an evidence based way and approached the same as regular old automatic negative thoughts. This is not typically helpful.
"What counseling methods/techniques can be helpful when working with clients with obsessive behavior and/or OCD? Please explain how this/these method(s) work well for this client population. If possible, please talk about a case example (without identifying information) who worked with you and showed improvement. What were his/her presenting issues, what methods did you use and what issues did you focus on in counseling sessions?"
Exposure and Response Prevention (ERP) is the GOLD standard treatment (which is a very specific subset of CBT). It is indicated as the starting point for all OCD treatment. This is a strong statement, but it is backed by the research (the most RCTs by far) and organizations like the IOCDF, APA, and so forth. SSRI (and Clomipramine, a TCA) medications are also first-line psychopharmacological treatments, though with less effect on average than ERP. Both combined can be helpful, though may not necessarily increase the overall benefit of just ERP alone. Another first-line treatment for OCD (though not the "gold standard") is Cognitive Therapy with Behavioral Experiments. Along with medications, it is seen as sometimes a more agreeable option for those who are hesitant to engage in exposure therapy (which intentionally and repeatedly provokes distress in order to respond differently- i.e., without compulsions).
Adjunct therapies, medications, and treatments are utilized. In the interest of brevity, research has discovered the integration of Acceptance and Commitment Therapy (ACT), Motivational Interviewing (MI), and other techniques can be helpful to provide well-rounded treatment and/or facilitate the practice of ERP.
To share a classic example [identifying factors changed to protect confidentiality- this type of case is remarkably common], one woman came to me with severely distressing thoughts about harming her children (no history of harm or abuse). She knew it was irrational, yet it felt so real to her; the more these intrusive thoughts continued to appear, the more difficult it was for her to determine her intent from confusing feelings and "impulses" to stab her kids. Upon receiving a diagnosis of OCD, I thoroughly assessed history with symptoms, and educated on the CBT model for understanding OCD treatment with a rationale for CBT and ERP. We discussed medication options, to which the client was willing to pursue with their Psychiatrist. The client was very cooperative due to a high willingness and intrinsic motivation to be able to engage at home with her two children and spouse. As can be very typical, the stress also took a toll on most every area of life, making work difficult. Once we began ERP, we started with doable exposures while learning how to stay present with triggers and distress- without compulsing. Upon successful practice of more manageable triggers on their hierarchy, they- with the incredible support of their spouse and church and loved ones- made a jump in their exposure work that began with "scripts" (imaginal exposure stating/writing distressing thoughts and quickly progressed to holding knives and stating these feared thoughts aloud) and transitioned to practices situationally at home, holding knives and saying scripts aloud (in separate rooms appropriately not in front of their young children). The incredible support around this client, along with a sense of strong purpose, helped facilitate (this is part of ACT) the integration of ERP into daily life. They would be considered recovered at this point, scoring so low on the Y-BOCS (gold-standard assessment in rating severity) that their symptoms are sub-clinical. In relapse prevention planning, they understand the chronic nature of OCD and the necessity of staying on top of their good progress, with the plan to follow-up at occasional intervals for "booster sessions." I gain so much joy from stories like these.
"People with an OCD diagnosis may be taking medication and seeing other professionals (psychiatrists, psychologists). How could a counselor work in tandem with these other professionals? Please include a case example, if possible."
Coordinating care can be difficult, but worth it for the best client care! Although seamless communication and record exchange between providers is likely ideal, it just rarely happens in real life. Working within the space and limits that exist, I have found that outside of those very few therapists and Psychiatrists I can have near immediate communication with, it is still very helpful and feasible to at least request/give one way communication to a provider. In complex cases, it is almost unheard of for me to not outreach another provider that is connected somehow to shared treatment concerns. I think we need to be realistic about other providers' schedules and communicate what we can- how we can. This often looks like me leaving a Psychiatrist a voicemail after release is given- and not hearing back- but at least they have the information. It may be coordinating with another therapist who is treating other concerns. Early on, I used to welcome other counselors working at the same time on separate diagnostic concerns. Though I may work with someone now who is seeing another professional for something like, say, Depression, it is usually quite imperative that I make known to the patient and also the other provider the pitfalls of feeding compulsions through reassurance, ruminating, and so forth. This is a great opportunity for education of those who are not specialists in OCD. But OCD being as debilitating as it is (2 out of 3 people experience severe impairment at some point in their life), I need to work hard upfront to educate especially the patient about how hard they will need to work (and not undermine) their exposure therapy. Also, many other comorbidities can often improve significantly just by treating the OCD first.
"How, particularly, are counselors a “good fit” for helping clients with obsessive behaviors? How can they help people with OCD differently than a psychologist would?"
It has been my personal experience that my colleagues who are counselors (Master's level, typically), bring to the table incredible creativity and "outside the box" thinking. Many of the hands-on resources, videos, blogs, and social media that exist to help the sufferer of OCD often come from Master's level clinicians. I believe there is great flexibility many of my counselor colleagues have (which is a positive and a weakness all at the same time, sometimes lacking the rigors of adhering to the evidence based treatment protocols).
There are actually quite a few more Master's level clinicians than Psychologists, and there is a great need for more clinicians offering great treatment. Counselors can help fill this gap.
"As a practitioner who specializes in working with OCD, is there anything else you would want counselors who don’t specialize in this area to know?"
For many reasons, I love work with clients who have OCD. I have found they are some of the kindest, hardest working, conscientious individuals on this planet. This is where I believe many of their personality strengths arise once moving through pathology. It is a joy every day to see recovery, growth, and maturity bloom out of suffering.
"Any main take-aways to share?"
OCD Treatment can be so rewarding! It has very effective treatments for most, very clear evidence, incredible improvement that can be witnessed in a short period of time, and there are wonderful opportunities to get invested in this world with a community of professionals, sufferers, and supporters who are incredible.
~Justin K. Hughes
Those who know me know that I see people as individuals and hate to make generalizations. However, it seems to me that those suffering from OCD are among the kindest and most understanding people I have ever met.
This post was originally published on 02/13/2014 on my wordpress and is newly updated.
“Why can’t I stop thinking about this?” “Why can't I stop? I know it doesn't make sense.”
William went to the Middle East after his unit was deployed from Ft. Hood. Most of what he heard about soldiers’ experiences were rumors and media stories- he had no way to be prepared for what would happen. After nearly 6 months of swallowing sand stirred up by 110 degree winds, William had 5 days left until he would return home. Momentarily losing his hearing, all his senses were shaken when an IED tore shrapnel through his three closest friends. They were dead. Just like that. After being rushed by helicopter for triage medical care, William soon discovered he only narrowly missed death- the same shards of nails and rocks that killed his friends were found inches away from where he stood.
Returning home is where cleaning up the fragments took the longest. After being debriefed and allowed medical and family leave, Bill struggled getting back to civilian life. Some of the most difficult times he faced were trying to overcome his own unexpected reactions to situations, usually late at night where he would awake from a noise, pulling his wife down from the bed onto the floor to take cover. When he became calm, he was covered in sweat, visually stunned by recalling what had happened weeks before- and so embarrassed to be dragging his wife- literally- into the center of his problems.
This is trauma. This is the story of William’s PTSD (post-traumatic stress disorder). Hopefully his story can help bring understanding to struggles faced by those dealing with trauma and respect for our service men and women.
It’s not very difficult to have some sense of empathy for William’s situation. It’s often much harder to understand another very real and very overwhelming problem. It is called Obsessive Compulsive Disorder (OCD). You may be curious why this article spends so much time talking about PTSD, only to discuss OCD. Two reasons. OCD actually has some similar features and neurobiology to PTSD, and secondly, if we are to listen to the struggles of others, often we must start with something we do grasp a little more readily.
Whether a person is triggered into feeling distress from trauma or obsessions, their brain is becoming hyperactive in warning of a threat. This wonderful system when working properly can be nightmarish when the reactions surface out-of-context. Think of the panic you would feel if you saw someone almost being run over by a car- your fight/flight/freeze response would activate and prepare the body and mind. Now imagine it occurring at random times and being uncontrollable.
Despite popular references of, “I'm so OCD” and “He really likes the house OCD clean,” [FYI, OCD is not an adjective] this diagnosable mental health condition is a serious disorder- and far beyond a person’s immediate ability to just “stop it.” Because the anxiety and distress a person with OCD feels is so bothersome and intrusive, they naturally seek to alleviate it- sometimes with elaborate mental rituals to “do away” with the anxiety (e.g., counting, prayer, neutralizing statements) and sometimes with physical compulsions and avoidance to feel better (e.g., “I feel anxious when someone touches my clothes and need to change and wash them immediately”). To some people, this sounds "crazy." But in our age of neuroscience (and OCD is remarkably well established), we cannot deny scientifically the paint and suffering involved in the sufferer's life. Their mind- and often body- SCREAM with discomfort until they do something to alleviate it. And the compulsion works! Momentarily, at least for a bit. It problematically, though, reinforces the learning, connections, and neural pathways linked to disorder as opposed to reinforcing healthy, non-compulsive behavior.
To stand up to OCD, a person needs to ultimately eliminate all compulsions. What do we make of this? Do we expect the person with PTSD to just jump back in to just get on with their lives? Nope. Let me be clear with OCD (and this is also true of PTSD).
There is hope and very effective treatment.
We don’t have to understand, ultimately, to love. As many as 1-3 % of the population wrestle with this. Look around- that’s someone in your neighborhood or at the restaurant where you ate. Will you lend a helping hand to those who suffer? I will.
Justin K. Hughes
Check out more resources on my page dedicated to them:
This video and guide below were specially formulated to help you be mindful in an "Exposure-Friendly" way.
This one's a bit different from the average mindfulness practice you might be familiar with. The reason it's called "Exposure-Friendly" is that it is specially designed to help a person be mindful of whatever they are experiencing, not just attempting to feel better. This is a hallmark of exposure therapy: being able to tolerate distress without engaging in pathological responses (rituals, safety behaviors) that negatively reinforce fear. Distractions and relaxation when facing our fears can backfire (see the research at the end of the Guide). So if we need a different set of tools to face fear, here's one of them. I hope it helps.
Music: As Leaves Fall
Thanks to Jonathan Hoxmark on Unsplash for this beauty!
Perfectionism and OCD
What is perfectionism? Oxford dictionary defines it as “refusal to accept any standard short of perfection.” That’s automatically problematic. Perfectionism leads to a circumscribed focus, stress, and suffering for not only individuals, but for loved ones nearby who feel the weight of being perfect.
Is this the same as OCD? Nope. OCD and perfectionism often get confused. They both can affect and drive distress in one another, but they are separate. OCD involves unwanted (intrusive) thoughts, urges, and impulses that cause distress; furthermore, compulsions are repetitive behaviors or thoughts that attempt to reduce distress or prevent something bad from happening. Perfectionistic manifestations of OCD, often referred to as “just right / not just right” fit this categorization. Separately, in Perfectionism, someone pursues “perfect” thought, behavior, or action initially out of interest or enjoyment (rather than to suppress an intrusive thought/urge/impulse, like in OCD). There are typically problems that go with this, however. So a difference between the two is that OCD is ego-dystonic and Perfectionism is typically ego-syntonic (you can check out my video here explaining the difference).
Examples of perfectionistic thoughts and behaviors[4,5]:
I am a "recovering" perfectionist. And it’s a problem when I’m not, well, “recovering” from it. One of the mechanisms that keeps perfectionism going is the belief that it is helpful (this is a “Positive Belief” about perfectionism, and it is a cognitive distortion). When I succeed at a task- and especially if I get a lot of praise, it is a natural reinforcer that I must be doing well. However, if I spent 8 hours researching, writing, and proofing this blog today, that is problematic for me at this point in life (and I easily can spend that much time). What is a problem or not sometimes depends on the person and their situation- maybe a journalist would spend that much time or even more, but I am a full-time clinician with a family, church, volunteer involvements, and hobbies. If I make this post “perfect,” in my perfectionism, I will seriously miss out on other things.
This pursuit of perfection doesn't stop with one blog post. It will always generalize if allowed. So if I let it, the pressure of perfection will continue (and does, at times) to move on to other things like caring for my home, caring for people in my life, my relationship with others, my diet, exercise, my spiritual walk, my car, money, and so on. And being honest with you, these things are tied up in anxiety and simultaneously selfishness- attempting to control these things rather than to engage with them/others in a meaningful way by learning to lean into the fear and live based on what is valuable.
Parenting is probably the single biggest event that pressed me with the realization I need really challenge my perfectionism. There are two stark realities to me in life: I can either do my work/relationships/home life/etc. “perfectly” and end up in an ever narrowing scope of anxious overwhelm trying to keep all the balls in the air, OR learn to tolerate the distress that comes doing things "not just right" and focus on the big picture, growing towards what I love and value. And the reality usually is that in time, this fear habituates when not engaging in avoidance, rituals, or control strategies.
Whether in therapy or personal life, to change how I behave and think and respond in life, I need to be aware/monitor what it is that needs to change (good therapy, support, and resources such as on my website can help). Even if I know what needs to be done, if I can’t effectively observe and catch it when it occurs, I will not be able to change it. Next, I will need tools and strategies to effectively grow and mature. In therapy, some of these are Exposure Therapy, Cognitive Restructuring, and more. In essence, at the point of the problem I must be able to insert the solution- and consistently. Lastly, I want to continue to monitor and gain feedback to incorporate learning and solidify growth. I don’t want to oversimplify this- if you are having a problem with any of the areas I have discussed, please reach out to a competent trusted person and/or therapist.
Today I gave myself the time limit of 3 hours- start to finish- to research, write, upload and post. And it’s simultaneously stressful and joyous at the same time. I’m going to do a behavioral experiment and keep doing it- “testing” whether or not my choice(s) in leaning into my fear of failure a) doesn’t end up as bad as it feels like it will, and/or b) I was able to handle or face it anyway. We’ll have to see- I'm leaning in!!!
Justin K. Hughes
 First of all, it’s a whole mess to even get into a truly perfect standard- if I make and continue to make mistakes, I am not perfect. I cannot even begin to conceive what perfect is, then, since I would make a mistake in defining “perfect.”
 The Diagnosis of Obsessive Compulsive Personality Disorder (OCPD) may apply when a person pursues perfectionistic behavior to pathologically disordered levels.
 Grayson, J. (2014). Freedom from obsessive-compulsive disorder: a personalized recovery program for living with uncertainty. New York: Berkley Books.
 Minirth, F. B., & Meier, P. D. (2015). Happiness is a choice: enhance joy and meaning in your life. Grand Rapids, MI: Spire.
In Vivo Exposure
Directly facing feared objects or situations, examples include:
Getting on a flight, touching a doorknob that feels “contaminated,” not going back to check a lock, or going to a social gathering.
Good exposure attempts to match the content and detail of a person's fear as close as possible. So, for example, if a person fears “going crazy” in a social setting, the best exercise will be working up to facing that, not just exposing to the thought or word. On the other hand, if the fear is that a person will have inappropriate impulses (to harm, sexually, etc.), sitting with the intrusive thought and being present will serve best.
Imaginal exposure involves accessing the content of fears and anxieties through cognitive means. For example, a fear that someone will fail, make the wrong decision, harm someone, die, or choose the wrong relationship are not accessed by activating these life occurrences. They are addressed imaginally.
There are many ways to practice Exposure imaginally, but the most common are writing scripts, stories, listening to recordings, watching videos, or using visualization.
To be clear, Imaginal exposure often is the most confusing and hardest to grasp of exposure practices, as it seems to be creating negative thoughts or “bringing” unrealistic and negative thoughts on- the seeming antithesis of most of psychology and cognitive therapy. But what is really done here is only facing what a person is already experiencing, thinking and feeling.
Intentionally bringing up physical sensations that are feared, such as:
Heart racing, shortness of breath, sweaty palms.
Ways to do this when a person's health allows are breathing through a cocktail straw, breathing rapidly, or sitting up quickly.
Virtual Reality (VR) Exposure
With the advent of new technology, we have a recently emerging type of exposure. Some may class Virtual Reality into imaginal exposure, but it can be seen as a cross between in vivo (situational) and imaginal. This is especially helpful with treating disorders such as Flying Phobia, where the access to an actual plane and flight to practice can be cost-prohibitive and difficult.
What is Exposure Therapy?
Exposure therapy is a psychological treatment that is practiced in Behavioral and Cognitive Behavioral Therapy (CBT). It is indicated as a first line treatment for a number of disorders such as
Exposure therapy helps clients to systematically confront fearful stimuli along with changing fearful responses. This relearning increases confidence and decreases disruption in life. Over time, discomfort and fear typically decreases through active engagement rather than avoidance, suppression, neutralization, or ritualization.
The evidence base is very strong for its use and effectiveness, though it is currently only applied a minority of the time in clinical settings.
How Do You Do Exposure Therapy?
The principles of exposure may be simple, but the specifics- personalized to any one individual- involve many working parts.
Do I want this, or do I not? Is this my actual desire, or what I don't want? Does this thought or desire define me? What if it's terrible or horrible?
Sometimes the things I think about are because I value them or desire them.
Sometimes the things I think about are because I don't value them or desire them.
What the heck?
Egosyntonic and Egodystonic are two psychological terms to describe phenomena of thoughts/urges that are synonymous and antonymous to what a person desires or wants. Sometimes our thoughts reflect very much what we desire or want, but around 90% of people endorse having "intrusive thoughts," or unwanted thoughts.
It is crucial to do a good functional analysis on a thought/behavior to determine whether someone is doing something in order to pursue- or to avoid- the very same thing.
Did your anxiety increase over flying after news of the engine failure on Southwest Flight 1380? Even a little?
I have booked plane tickets twice since the incident in mid-April 2018, and when choosing seats, I hovered precariously as I decided whether to select my favored window seat, or if I go for the "safer" aisle. My wife mentioned slight concern over the window seat because of the tragedy that occurred.
Working closely with the CBT treatment of Anxiety Disorders and OCD, I knew the moment I read the news- first about engine failure and the sad death of a wife and mom, Jennifer Riordan, and more recently the loss of cabin pressure and a window crack on a separate flight- there would be increased fear and anxiety about flying. Why? Flying commercially is statistically more safe in the U.S. than it’s ever been. Even with these incidents. Even with 100 of these incidents.
The fear is natural, and even normative, to some extent. It makes sense that we’d instinctually be a bit curious about our well-being in a metal tube soaring at 500 mph with tons of jet fuel propelling it. Even the possibility of flight has been denied in most of human history.
But what about when fear starts to cause problems ? Affect choices? Leads to avoidance of life pursuits and goals? Or becomes one more in a cumulative list of anxieties and worries? One way to be 100% certain that you will increase your fear load is by giving the aforementioned flight(s) unrealistic credit. By associating personalized, catastrophic meaning to a situation that is one of the safest things you can do (safer than riding a bike), a distortion has taken place. Some disorders, such as Specific Phobias, PTSD or OCD, make it pathologically difficult (i.e., neurobiologically) to change how one feels and thinks, regurgitating fear quicker than your vertigo-experiencing seatmate with their airline-branded “barf” bag.
With Flight 1380 being the first fatality on a U.S. passenger airline since February 2009 (over 9 years), flying on a plane is a remarkably secure form of travel. Unconvinced? Check out Forbes’ mining of some reputable stats.
Here’s the thing; education and stats are helpful, but only go so far. Fear is more than a reasoning thing- or in neuro terms, more than a prefrontal cortex (PFC) thing. Fear is an emotional thing. An amygdala thing. A learned response and genetic thing, along with a pervasive attitude and decision thing. It’s something that can destroy, harm, and erode, or it’s something that can be used in its rightful context, and set aside when not useful (e.g., PTSD treatment where a person can balance both safe and smart decisions, while facing disordered fear, so they can live life more fully).
So if you’re like most people who need a bit more than statistical education to counter anxiety and become stress resilient, remember this:
What you think and believe (cognitively) is vitally important.
What you do (behaviorally) is vitally important.
Your health and well-being are intricately tied to these. Small decisions today can lead to a long-term impact. For many of us, the greatest threat we face today is fear. So I chose the window seat.
“I am an old man and have known a great many troubles, but most of them never happened.”
“Security is mostly a superstition. It does not exist in nature, nor do the children of men as a whole experience it. Avoiding danger is no safer in the long run than outright exposure. Life is either a daring adventure, or nothing.” – Helen Keller
I don’t want to live my life being overly cautious, but rather appropriately cautious.
We are discovering in the research of anxiety disorders, OCD, and now depressive disorders, that possessing an Intolerance of Uncertainty (IU) is a common construct linked with higher anxiety and life disruption.
What is IU?
My favorite definition: “Belief that uncertainty, newness, and change are intolerable because they are potentially dangerous” (Steketee et. al 2005, p. 125). IU links threat with uncertainty.
But is uncertainty a threat? Take a moment and ponder one of your favorite memories. What did it involve? Was there any risk? Any vulnerability? Any chance of failure? Most of the best life stories I hear are of those that involve, well, all of these things.
A person who cannot tolerate not knowing actually misses out. How? Isn’t knowledge power?
What happens is this: the more control a person must have, the less control a person has. The more certainty that is sought, the more narrowly circumscribed life becomes. Quick examples:
Want to know how you handle uncertainty? Take the free IUS-12 assessment here. [Go to "Read More" below to find out how to score the assessment.]
Let’s be clear: everyone is uncomfortable with some uncertainty. And reasonable protection from risks is part of being wise- which can also be subjective. But the more you necessitate that certainty must exist, the following is more likely to happen:
In the research on IU, there are also two subset strategies identified: Prospective anxiety (desire for predictability) and Inhibitory anxiety (uncertainty paralysis) (Fourtounas et. al 2016).
If you struggle with any of these, the next questions is this: How do I live with uncertainty and anxiety, while also taking suitable precautions?
The solution is fairly straightforward, but not easy.
Once a problem area has been identified (along with what is reasonable, normative, or within your values), gradually and consistently gain ground by pressing into your fear without using a false reassurance strategy that reinforces the false threat of uncertainty.
In therapy, one of the most powerful tools that exists to deal with uncertainty is what we call Exposure and Response Prevention (ERP). This is the single most effective tool in treating OCD, and it is very valuable in other disorders. The reasons it usually has to be done in therapy are several:
I personally love Exposure because it helps me face life with a “bring-it-on” attitude rather than a “stumble-through-best-I-can.” ERP in therapy is very specific, very structured, and very powerful. However, even the person who is not in therapy can benefit from its principles:
“Some men storm imaginary Alps all their lives, and die in the foothills cursing difficulties which do not exist.” ~Edgar Watson Howe
So what uncertainty are you not letting yourself live with? When is ‘not knowing’ unacceptable to you? Uncertainty is not the problem. It is unrealistic to be 100% certain about most everything in life. Life has few certificates of guarantee, and those are only as good as what is backing them. Ready to face your uncertainty?
A Psychotherapists' thoughts on healthy living.
All Content on this Site, justinkhughes.com, was created for informational purposes only. Content is not intended as a substitute for professional advice, treatment, or diagnosis. Always seek the advice of your own personal health provider who is qualified to treat you, along with asking them any questions you may have regarding medical or other conditions. Never disregard professional medical advice or delay in seeking it because of something you have viewed on justinkhughes.com. Also, due to the sensitive nature of topics and material covered through this Site, which contains very descriptive and/or advanced content, you may not want to use justinkhughes.com. The Site and its Content are provided on an "as is" basis. Some posts are written for specific populations (OCD, Christians, Professionals)- with the intent to remain respectful to all- some content may not fit or go counter to your beliefs, perspectives, and what is explored for you in a professional counseling session with Justin K. Hughes, MA, LPC. The posts are intended solely for the population they are written to and can be designated by their titles and tags.
Links to external educational content are taken at your own risk. Justin K. Hughes, MA, LPC is not responsible for external content.