Therapy in a nutshell ocd

I once was working with a young man who had a lot of social anxiety. We’ll call him Miguel. 

Miguel had a good group of friends, but every time he hung out with them he would start to feel really anxious. And then when he was at a party he would make some joke or say something, and then he’d start to worry: “Did I say the wrong thing? Did I hurt her feelings?” 

Or if one group of friends split off to the pool and another invited him to the game room, he would panic a little, feeling terrified — terrified because he didn’t know which group to go with. 

Then he’d start thinking “Oh, I can’t believe I’m getting anxious again. I’m such a loser.” And then he’d think “Don’t think that way! What’s the matter with you? Don’t feel anxious! Why do you always do this?” and he would start going back and forth in his head, fighting his negative thoughts and trying not to feel anxious. 

And if he couldn’t get his anxious thoughts to go away, he’d feel uncomfortable and go home early. 

In this example, Miguel was fused with his thoughts in two ways. The first way was that when he was trying to hang out with his friends, he got all wrapped up in trying to make his thoughts go away. He was focusing all his energy on fighting his thoughts, and that kept him stuck or fused to them instead of putting his energy into having a good time. 

The second way that he would get fused with his thoughts is that he had an unwritten rule that he didn’t even know about. He didn’t notice he was thinking it, and it colored everything he did. 

Let me show you:

When I asked Miguel why he would get anxious, he said “Well, I always worry that I might say something wrong or that I might offend someone or hurt someone’s feelings.” 

 And I asked “What do you mean?”  

He said “Well, I always overthink everything I say. After hanging out, I always worry that something I said might have bothered someone or that a joke I made might have hurt someone’s feelings, and I just hate dealing with the drama.” 

“What drama?” I asked. 

“Well, let’s say a couple of my friends invite me to do something with them but they don’t invite my other friend, and then my other friend invites me to do something that same night. How do I say no to the other friend without making them feel bad?”

I asked a followup question. “So they aren’t being dramatic; you’re just worrying?” 

He said “Yeah.” 

“What are you most afraid of?” I asked.

“That I might make someone feel bad by saying no,” he responded.

I realized something and said “Sounds like you have a rule in your head that you’re never allowed to ever make anyone feel bad.”  

He thought for a second. “Hmm, I guess so. I never noticed that I had that rule, but now that you say that I think you’re right. Once I had a girlfriend who I wanted to break up with, but I didn’t for like a year because I didn’t want to make her feel bad.” 

 “Yeah, that’s a great example.” I said

“Or if the food is terrible or cooked wrong at a restaurant and the waiter asks how’s the food, I always say ‘great,’ even if it’s a lie.” 

This young man didn’t realize he was thinking “I can never make anyone feel bad,” and this rule that he didn’t know he had was making him really anxious. He had bought that thought — believed it — without even noticing that he was thinking that way.

In Miguel’s case, he was stuck to his thoughts. This was keeping him from being present with his friends. When we buy our thoughts, when we believe everything we think, it makes it hard for us to change. 

The first one is inflated responsibility. So this is where you believe that you are responsible for preventing bad things from happening to everyone. It’s epitomized by the nursery rhyme “Don’t step on a crack or you’ll break your mother’s back.” 

People with OCD may obsess over every little thing they do, as they feel personally responsible for preventing others from getting cancer, getting in an accident, losing their job, or even they feel responsible to prevent natural disasters from happening. 

The magical thinking leads to compulsions like “I have to pace 100 steps to prevent an earthquake from happening” or “I have to drive around the block 20 times to make sure that the speed bump wasn’t actually a person.” 

Now, while a person with OCD may logically know that doing the compulsions doesn’t actually prevent something, they still may fear that if they don’t do their ritual and then something bad does happen it would be their fault. So they do the compulsion anyway. 

It’s like an attempt to gain control over something that we can’t control. It’s the uncertainty of not knowing if something bad will happen. So for someone with OCD, that uncertainty is extra uncomfortable, and compulsions are an attempt to make that discomfort go away. 

The idea of repressed memories goes all the way back to Freud, through the 90’s when therapists accidentally implanted people with false memories, through the courtrooms, and into today where the idea of repressed memories is still popular among lay people and controversial among therapists and researchers. So today you’ll learn three skills for better understanding lost memories, aka dissociative amnesia or repressed memories (or at least my opinion about it). The idea of repressed memories goes all the way back to Freud, one of his first patients, Anna O had all sorts of unexplained physical symptoms, when she began talking with her doctor about her life, previously forgotten memories of trauma came back and as she talked about them, her physical symptoms went away. Freud developed the concept of repression, that current symptoms are all related to something that happened in the past, that we repress the memories to protect ourselves, and that we must analyze our psyche in order to uncover it, integrate it and then be freed from it. So that’s where the whole process of psychoanalysis came from, the idea of patients laying on a couch, talking about their childhood. But this concept of repressed memories has become very controversial, because of the way memory works. Most people assume that memory is like a video, your memory records things as they actually happened and stores those memories away, permanently. But memory doesn’t work like that, memories are highly influenced by our biases and how we’re feeling during or after an event. Even Freud learned that many of the things that his patients “remembered” weren’t actual events. Memories can be altered, implanted, influenced, and straight up created under suggestion. Lot’s of laboratory experiments have demonstrated that our memories are terribly fickle.
If you want to see for yourself how this can work, watch this YouTube video “Take This Test and Experience How False Memories Are Made”.
After I filmed this video on repressed memories and dissociative amnesia, the NYT published a very relevant article and two strong opinions on it:
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Therapy in a Nutshell and the information provided by Emma McAdam are solely intended for informational and entertainment purposes and are not a substitute for advice, diagnosis, or treatment regarding medical or mental health conditions. Although Emma McAdam is a licensed marriage and family therapist, the views expressed on this site or any related content should not be taken for medical or psychiatric advice. Always consult your physician before making any decisions related to your physical or mental health. In therapy I use a combination of Acceptance and Commitment Therapy, Systems Theory, positive psychology, and a bio-psycho-social approach to treating mental illness and other challenges we all face in life. The ideas from my videos are frequently adapted from multiple sources. Many of them come from Acceptance and Commitment Therapy, especially the work of Steven Hayes, Jason Luoma, and Russ Harris. The sections on stress and the mind-body connection derive from the work of Stephen Porges (

ERP Therapy – A Good Choice for Treating Obsessive Compulsive Disorder (OCD)

Janet Singer’s son Dan suffered from obsessive-compulsive disorder (OCD) so severe he could not even eat. What followed was a journey from seven therapists to…Read More

During OCD Awareness Week this past October, I sat in front of my computer, mesmerized, as I watched a live internet broadcast of first-person OCD stories. At the same time these stories were being broadcast, there were chat rooms open where people could connect and talk about anything related to OCD. I joined right in, letting everyone know that while I was not an OCD sufferer myself, my twenty-year-old son had recently recovered from severe OCD. I wanted to share our story as well as learn all I could about the disorder.

At one point during the chat, I connected with a distraught young woman who had been seeing a therapist for quite some time, but her OCD was getting worse, not better. “Is the ERP Therapy too difficult for you to do?” I asked her. “ERP Therapy?” she responded. “What’s that?”

I was stunned, though in retrospect I’m not sure why. Our family had floundered and then fought our way through a disorienting maze of treatments and programs, desperately trying to find the best help possible for Dan. But I had thought Dan was the only one who had been steered in the wrong direction, sent to the wrong therapists, and put on the wrong medications. It was then and there that I became an advocate for OCD awareness.

Exposure Response Prevention Therapy (ERP Therapy) is a type of Cognitive Behavioral Therapy (CBT) and, in my son’s case, a very effective treatment for OCD. In a nutshell, this therapy involves the person with OCD facing his or her fears and then refraining from ritualizing. This can be extremely anxiety provoking initially, but eventually the anxiety starts to wane, and can sometimes even disappear. A concrete example of ERP Therapy in action would involve someone with OCD who has issues with germs. They might be asked to touch a toilet seat and then refrain from washing their hands. Treating OCD with ERP therapy has even been the topic of some reality shows over the past few years. So why do so many therapists remain in the dark?

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When Dan diagnosed himself (with the help of the internet) at the age of seventeen, he was referred to a well-respected clinical psychologist in our area. This therapist employed traditional talk therapy, which included examining underlying issues. This form of therapy is not usually effective in treating OCD. In fact, talk therapy often exacerbates OCD. Talking about their fears over and over and reassuring OCD sufferers only adds fuel to the fire. OCD is not something rational that can be discussed. It is a neurologically based anxiety disorder. In fact, a study done in 2007 showed that OCD sufferers had less gray matter in the areas of the brain associated with suppressing responses. Telling someone with OCD not to worry is like telling someone with asthma to stop having trouble breathing. It isn’t possible. And so Dan spent months in therapy, getting worse. He ended up spending nine weeks at a world-renowned residential program for OCD, and that was his, and our, first introduction to ERP Therapy.

You don’t have to go to a residential program to get the right help for OCD. But you do need to find a properly trained therapist who specializes in the disorder. What works for one OCD sufferer may not always work for another. You and your therapist will work together to find the right balance of therapy, medications, and stress management techniques that will give you the best chance of success. The best resource out there for finding these competent therapists is the International OCD Foundation. Not only do they list health-care providers by state, they give you tips on what questions to ask when “interviewing” a prospective therapist.

ERP Therapy is difficult, but with hard work the OCD sufferer can improve dramatically. Three years ago Dan was so debilitated by severe OCD that he could not even eat. ERP Therapy literally saved his life and today he is a rising senior in college with a wonderful life ahead of him. We’ve got to get the word out that this is often a very effective therapy for those with OCD. Having OCD is tough…getting the right help shouldn’t be.

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