What I learned from one of the most famous OCD therapists in the world
It’s important to me that I learn and know everything I possibly can about OCD. That’s one of the reasons I spent years researching, and then publishing my work, on the biogenetic causes of OCD (My OCD research was relied on by The International OCD Accreditation Task Force in creating knowledge and competency standards for the treatment of adult OCD).
Knowing what causes and maintains OCD is one thing. Knowing how to help others heal OCD is another. So, over and beyond learning about the causes of OCD, I’m constantly on the lookout for, reading, and listening to everything I can get my hands on related to OCD treatment.
This search for knowledge is what led me to the work of Jonathan Grayson, probably one of the most well-known OCD therapists in the world. In early 1980s, Jonathan collaborated with Edna Foa (one of the world’s best OCD researchers) in transforming OCD treatment, including being instrumental in the development and spread of exposure and response prevention treatment (ERP) for OCD (see, for instance, Jonathan and Edna’s famous 1983 article Success and failure in the behavioral treatment of obsessive-compulsives).
William and Dr. Jonathan Grayson
Agreeing to Treatment
Since that time, Jonathan has been a leading advocate, therapist, and clinician trainer within the OCD world. As part of his work, he authored the outstanding book Freedom from Obsessive Compulsive Disorder: A Personalized Recovery Program for Living with Uncertainty. Reading it, you’ll find a comprehensive review of the ins-and-outs of ERP treatment for OCD. Importantly, Jonathan emphasizes an element of ERP treatment for OCD that is often not highlighted in other OCD resources (and not emphasized in a lot of OCD treatment). I review this element below.
Has the client agreed to treatment?
Jonathan reviewed how he frequently works with clients who have participated in ERP treatment in the past but have not achieved the improvement they were looking for. He described that a typical cause for clients not achieving the improvement they were looking for is that they, and their therapists, did not ensure that the client had agreed to treatment.
What in the world does this mean? How could a client and a therapist work together, sometimes for years, when the client has not agreed to treatment?
For Jonathan, agreeing to treatment means that the client has agreed to learn, and practice, living with uncertainty.
Alexa’s Example
To illustrate what I, and Jonathan, mean, consider the example of my clinical work with Alexa.
Alexa came to see me because she had terrifying thoughts, images, and feelings related to harming her children. These images included numerous ways she might kill her children, including strangling them, stabbing them, running them over, and throwing them from high places.
Being the intelligent woman she was, Alexa eventually discovered that her experiences were likely caused by OCD and that she would likely benefit from ERP treatment. Alexa found an ERP therapist and began therapy.
Unfortunately, Alexa didn’t much improve. After almost two years of treatment, she came to see me. When Alexa and I reviewed her previous interaction with ERP therapy, including what appeared to be helping and what wasn’t working, she and I identified that Alexa was still frequently participating in safety behaviors (both avoidance behaviors and compulsive behaviors).
“This is almost certainly why your ERP treatment isn’t working” I told Alexa. “In order to reduce the frequency and intensity of your intrusive thoughts – and related anxious, painful feelings – we’ve got to reduce, and work toward eliminating, your safety behaviors.”
“I know, I know” Alexa told me, “but when I’m preparing to do an exposure, or if I’m just going through my day and I have an OCD experience, I become so scared that not completing my safety behaviors becomes too much to handle. I just can’t keep from doing my compulsions knowing that, if I don’t complete my compulsion, I might harm my kids.”
Aha! In the paragraph above, Alexa identified the core obstacle in her treatment. That core obstacle was Alexa’s unwillingness to take calculated risks in overcoming OCD (otherwise known as Alexa’s intolerance of uncertainty).
No matter what Alexa does, she will never, ever, obtain a 100% guarantee that she won’t harm her kids. What are the chances that she’ll harm her kids? Very low. But not zero. And it’s this but not zero that keeps Alexa participating in her safety behaviors.
When Alexa and I reviewed this, she told me, “But William, what kind of mother would I be if I didn’t do everything I can to keep my kids safe? How could I have the thought of stabbing my daughter and then keep chopping vegetables while my daughter is with me in the kitchen?”
Believe it or not, when Alexa tells me messages like the above, what Alexa is actually telling me is that she believes she should complete her safety behaviors.
This puts Alexa in a bind.
On the one hand, if it’s true that Alexa should complete her safety behaviors, then she probably shouldn’t continue to work with me (as I’ll be recommending that she abstain from her safety behaviors). On the other hand, Alexa believes that she does have OCD, that her OCD is severely damaging her life and her relationships, and that ERP treatment, including abstaining from safety behaviors, is what she should do to overcome OCD.
And, thus, Alexa found herself confronted with a choice point. This choice point included facing questions such as:
Should I abstain from my compulsions?
How do I know for sure that something terrible won’t happen if I abstain from my compulsions?
Taking Calculated Risks
The answer to the question “How do I know for sure that something terrible won’t happen if I abstain from my compulsions?” is: Probably not. But maybe.
And so Alexa and I reviewed that being alive is an exercise in taking calculated risks.
Is it a risk if Alexa doesn’t complete her safety behaviors? Yes. Not a likely risk (I’d never encourage a client to perform any behavior that’s realistically risky), but a possible risk.
On the other hand, is it a risk if Alexa continues to complete her safety behaviors? Yes. In fact, it’s a very, very risky thing for Alexa to do. Because her safety behaviors feed her OCD, keep her stuck in a cycle of intrusive thoughts, anxious feelings, and cause damage to her life and the life of her family.
This way of framing Alexa’s choice point allowed Alexa and I to explore why she might be willing to take the calculated risk in abstaining from her safety behaviors and the commitment involved in doing so. This included us reviewing scary ideas about the future, even Alexa and I reviewing Alexa’s guess as to the thoughts and feelings I might have if she successfully abstains from her safety behaviors and then she does, in fact, hurt her children.
“What do you think I’d think about your decision to abstain from safety behaviors if, in an inexplicable turn of events, your abstaining results in you harming, or killing, your kids?”
“You’d be very sad for me if that’s what happened. But you’d be proud of me for stopping my safety behaviors” Alexa told me.
“But Alexa,” I responded, “why would I be proud of you for, in essence, making a mistake? Because, from an omniscient point of view, it turns out that not completing your safety behaviors was a mistake?”
Alexa smiled (because we’d explored this before), “Because I don’t get omniscience. No one does. All I get is my best, most well-informed guess. And my best guess led me to the conclusion that I have OCD, OCD is hurting me and my family, and abstaining from my safety behaviors is the best way I, you, and clinical science know to overcome OCD.”
After some months reviewing the pros and cons of taking the leap in abstaining from safety behaviors, including detailed review of Alexa’s core fears, Alexa chose to go “all in” on her OCD treatment.
This process was Alexa agreeing to treatment. And after she made the leap, her healing process unfolded exactly as the clinical science suggests it would.
I want to highlight that agreeing to treatment is not the same thing as:
Meeting with me weekly (even meeting with me three times a week)
Knowing what OCD and ERP are
Knowing that overcoming OCD requires ERP and abstaining from safety behaviors
Agreeing to treatment is knowing all of these things and then being willing to put that knowledge into practice.
It’s the bravery involved in putting the knowledge into practice, not obtaining the knowledge itself, that’s usually the hardest part of OCD treatment.
I discuss the process of identifying values, accepting uncertainty, taking calculated risks, and commitment in other blog posts and I hope you’ll take the time to explore them.