Chaining in OCD Treatment
It’s not uncommon for my clients to report to me that chaining has been one of the quickest and most effective skills for helping to manage their OCD. What is chaining and how does it work? These are the questions reviewed in this post.
Chaining is a form of abstaining from compulsions. Chaining involves identifying a thought as an intrusive thought, allowing the thought to be present, allowing the anxious, painful feelings to be present, and abstaining from compulsions for a period of time.
How is chaining different from simply stopping our compulsions? The primary helpful feature of chaining is that it provides us leverage in abstaining from our compulsions. How does chaining do this? Let’s explore some examples to see how.
Sadie’s Example:
Sadie came to see me as a result of her OCD-related experiences increasing to the point where it had become very difficult for her to function. Her OCD showed up in numerous ways. But for the purpose of discussing chaining, we’ll focus on only one of her significant OCD themes: “What if I said something terrible when I was with others?”
Sadie reported to me that upon leaving any social gathering, she’d immediately have the thought “What if I said something terrible while I was at that social gathering?” This thought activated anxious, painful feelings right away and was related to a very scary story where she lost friends, her job, and was even “cancelled”.
Because Sadie found the intrusive doubt that she might have said something terrible distracting and scary, she understandably wanted to make the thought go away. Her primary method of making the thought (and related anxious, painful feelings) go away, was to mentally review everything that occurred during her time at the social gathering. In her mind, she’d walk through, step-by-step, each detail from her time at the gathering, replaying every interaction. Her review would be very comprehensive, including her recollection of what she said, her body movements, and how others reacted to her.
Unfortunately, as is so common in OCD, Sadie often doubted if she was remembering what happened correctly and, thus, she’d end up rechecking her memories again and again, frequently for hours, before she felt like she was “certain enough” that she didn’t do something terrible.
When Sadie and I reviewed this situation, we agreed that, although she couldn’t be certain she didn’t do something “terrible” in a social situation, it seemed very unlikely she did and the doubts and anxious feelings she was having was probably her OCD.
Of course, as always in ERP treatment, we emphasized that her doubts sure did seem like OCD but maybe those doubts are not OCD and Sadie really did do something terrible. And, if she realized she’d done something terrible now (by completing a memory check), she can get a jump start on apologizing and damage control. This process might save Sadie from losing friends, her job, getting cancelled, etc.
At the same time, Sadie also realized that while inexplicably doing something terrible was a possible risk, her OCD appeared to be a much more likely and dangerous risk. And, after reviewing her values and willingness to take calculated risks, we began ERP treatment.
Initially, Sadie reported it felt far too scary for her to go “cold-turkey” from her memory checks. Thus, instead, we explored her willingness to chain.
“Here’s what I’d like you to try after your next social gathering” I explained to Sadie. “After you leave the gathering and you have the thought ‘What if I said something terrible?’ I want you to say to that thought something like, ‘OK, I see you. That’s a scary thought and, although it’s probably my OCD, maybe it’s not. However, I’m not going to do a memory check right now. And, at the same time, it feels too scary and overwhelming to make the decision to never memory check. So, I’m not going to ignore that thought forever. Instead, I’ll come back to that thought and, if needed, do a memory check. But I’m going to wait at least one hour before I do that memory check.’”
Sadie had tried to entirely abstain from memory checks before but always was unsuccessful, largely because the anxiety she felt related to entirely abstaining felt overwhelming for her. However, when Sadie was able to tell herself “I’m not ignoring this thought forever, I’m just not going to do a memory check right now”, she was still anxious but significantly less so. And, as happens so frequently when my clients begin chaining, by the time they reach the agreed upon time in the future where they’ve planned to complete a memory check, they no longer feel the need to do so.
In Sadie’s case, she very quickly reported great results with chaining.
“William!” Sadie explained to me after a few weeks of her chaining practice, “I was with friends last night and I even had a drink (having even a drop of alcohol made Sadie especially nervous because it activated thoughts such as “What if I did something terrible and I don’t remember because I was intoxicated?”) and, when I was driving home, I told myself I was going to chain the thoughts until after I brushed my teeth. And by the time I finished brushing my teeth, a few hours later, I was already feeling much less anxious. Since I was already feeling much less anxious, I did what we talked about and chained the thought again, saying to myself ‘OK, I’m not going to do a memory check now but, if I feel the need to do a memory check tomorrow morning, I’ll do that memory check with my cup of coffee.’ And you know what? When I woke up the next morning, I was barely anxious at all! So I decided to chain the thought again, this time saying I wasn’t going to do my memory check until I met with you at our appointment today. But now I don’t feel anxious about the situation at all!”
Although Sadie had other OCD-related areas in her life that required more in-depth ERP work, practicing chaining, on its own, drastically reduced her intrusive thoughts, anxious feelings, and compulsions around this important area of her life.
Charlie’s Example:
When Charlie and I worked together, his concern was similar to Sadie’s in that Charlie was concerned that he might inexplicably do something terrible. The difference between Sadie and Charlie’s concern was that Sadie was primarily concerned that she might say something terrible whereas Charlie was primarily concerned that he might do something terrible. Charlie’s typical fears where that he might assault, molest, rape, or murder someone.
Due to Charlie’s typical intrusive thoughts, he did everything he could to avoid being in situations where he was alone with another person (being around groups of people acted as reassurance for him that he didn’t do something wrong because others would have noticed and intervened). Thus, for example, Charlie would avoid elevators because he was terrified of being alone in an elevator with another person (e.g., “What if I molest this person while I’m on the elevator with them?”).
As part of Charlie’s OCD treatment with me, we reviewed the importance of reducing and then eliminating Charlie’s safety behaviors / compulsions, both physical and mental. Like Sadie, one of Charlie’s go-to mental compulsions was memory review.
Charlie was excited to report to me one of his breakthrough successes with chaining:
“William” Charlie said to me, “I went to the theater performance I told you about. I really needed to use the restroom during intermission. And you can imagine how scared I was when I went into the closet bathroom and it was, surprisingly, not that busy. When I walked in there were only a few people in there and, as you can imagine, I was nervous about the possibility that I might be alone with someone in the bathroom. And then it happened. One-by-one the other men in the bathroom finished using the urinals and were leaving to wash their hands and then it was just me and one other man at the urinals. I suspected the men washing their hands would be leaving the bathroom soon. I got really scared. I know I’m not supposed to do this, but I stopped peeing before I completely emptied my bladder because I wanted to get out of the restroom before I found myself alone with the guy next to me at the urinals. But, even though I stopped peeing before I emptied my bladder, by the time I turned around to go to the sink, I realized that the other men had already finished washing their hands and had left. I was alone with the other guy still using the urinal. I know you know how scared I was. And I know we’re working up to me being able to be in a situation like that and use my ERP skills. But I was so scared that I just decided to leave the bathroom right away. I didn’t even wash my hands. Anyways, all of this was the background for what happened next. You probably already guessed that I was having a lot of doubts if I had attacked or raped the man in the bathroom. And I really felt the anxiety and the urge to do a memory review. But I remembered our plan for me to chain and I did it! I said to that doubt, ‘I see you and I will get to you but I’m not going to get to you right now. I’m going to wait to do a memory review until I get home.’ I was still scared. But knowing that I could do my memory review when I got home calmed me down a little bit. Like we talked about, I kept reminding myself that the doubts can be there but I’m going to delay participating in them or doing the memory checks. And the doubts were there throughout the last half of the theater performance but I just let them be there, knowing that I can do my memory check later. And you know what? As the performance continued, I started to feel better! And by the time I got home, I was so much less anxious that I was able to chain the memory check again until the next morning. And by the time I woke up, I was barely anxious about the situation at all. Chaining is the best!”
As you might already suspect, chaining isn’t a direct substitute for head-on ERP work. Chaining can be thought of as a skill that’s related to a graded hierarchy, in that it allows us to participate in a treatment-related behavior that is challenging but not overwhelming. And, as I hope the examples above illustrate, chaining can be a very effective part of a comprehensive ERP treatment program which can provide substantial improvement in a short amount of time..