OCD and Intolerance of Uncertainty: Treatment Issues

Journal of Cognitive Psychotherapy: An International Quarterly Volume 24, Number 1 • 2010

OCD and Intolerance of Uncertainty: Treatment Issues Jonathan B. Grayson, PhD Anxiety and OCD Treatment Center of Philadelphia

Recognition of the importance of intolerance of uncertainty (IU) as a critical cognitive distortion in anxiety disorders has been growing. The clinical challenge for researchers and clinicians is to understand the nature of IU and what it means to help clients to cope with it. Obsessive compulsive disorder (OCD) is the ideal diagnosis to examine the challenges IU can present, since, in the author’s opinion, it is the core of almost all manifestations of OCD. The article then focuses upon three factors in which IU factors play a role in successful/unsuccessful treatment: (a) the role of the therapist in helping the sufferer to understand IU and the goals of treatment; (b) techniques for helping the sufferer to accept and carry out the goals of treatment; and (c) patient factors/problems leading to “resistance” in coping with IU.

Keywords: uncertainty; OCD; CBT; treatment resistance; anxiety; cognitive distortions

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would like to begin the consideration of intolerance of uncertainty (IU) with a cliché: IU is more than a clinical issue; coping with uncertainty is a challenge for everyone. Clichés are frequently viewed as a superficial understanding of a problem; for example, Shakespeare’s Othello is about jealousy. If you accept this analysis of Othello in lieu of reading/seeing the play, then it is sophomoric. In reality, a good cliché is shorthand for a concept requiring a deeper examination to truly understand its implications. Simply defining IU as a cognitive distortion does not capture the complexity of what it is, how its presence dictates treatment choices, and what kinds of factors can make it difficult to address. The pervasiveness of IU in anxiety disorders makes it necessary for us to understand how to best help clients cope with it. Obsessive compulsive disorder (OCD) is the ideal diagnosis to examine the challenges IU can present, since, in my opinion, it is the core of almost all manifestations of OCD. For purposes of this essay, three factors that influence treatment success will be discussed: (1) the role of the therapist in helping the sufferer to understand IU and the goals of treatment; (2) techniques for helping the sufferer to accept and carry out the goals of treatment; and (3) patient factors/problems leading to “resistance” in coping with IU.

UNDERSTANDING IU AND TREATMENT GOALS: DOES THE THERAPIST UNDERSTAND? In the more than 30 years I have devoted to treating OCD, my belief that IU underlies almost every manifestation of OCD has been reinforced by the response of countless sufferers to my

© 2010 Springer Publishing Company DOI: 10.1891/0889-8391.24.1.3

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explanation of the role of IU in OCD, and how their attempts to be 100% certain are the source of their anxiety. Suddenly, they no longer feel crazy or out of control. It is not simply the logic of the explanation; it feels true and accurate to them. Having a context to understand the source of endless urges and rituals makes sense and provides them with hope that treatment can work for them. At my treatment center, clients are told the goal of treatment is to learn how to live with uncertainty, because none of us know how to be 100% certain. We go on to say that as far as we can tell, the only people who are certain are stupid people, and we do not know how to make clients stupid. The fantasy of attainable absolute certainty is further driven home by asking clients to think of someone they love and then asking, “Is that person alive?” In response to their yes, our counter is: “How do you know? Is not it possible that your loved one has just died and you have not yet been informed?” Most of the time sufferers agree and unless this question is the focus of their OCD, they cope with this uncertainty the way “normal” people do; that is, they pretend their feeling of certainty is real. Their plan for coping with the potential loss is to wait for a terrible phone call. We also ask how they feel about being maimed and paralyzed in a car crash—noting they have risked death just to see us. The point is that most clients know how to live with uncertainty outside of their presenting OCD problems. The potential terrible losses they and we cope with become the feared consequences (FCs) of their obsessions. The goal of treatment—learning to live with uncertainty—means learning how to cope with their FCs in the same way they cope with their non-OCD potential life disasters. Too many therapists approach IU with a superficial understanding. Because their clients’ fears do not trigger any of their own fears, they apply their own subjective judgment about how the client should feel. Usually the client’s anxiety and concern resulting from IU is incorrectly treated as if the problem was simply a poor assessment of the probabilities. This is the proper approach for a fear in which IU is not a factor. Such therapists will have some successes, but it is questionable as to whether their outcomes will be as robust. Consider the following two examples with regard to trying to use probability assessment to treat IU fears. 1. If a socially anxious individual is afraid that there might be people at a gathering who disapprove of him or her, most therapists will assume that some people probably will feel this way and treatment will focus on ways to cope with this possibility and its associated FCs. 2. Now consider the case of an OCD sufferer, who is concerned that his thoughts might harm another. Some cognitive therapists tend to ignore the IU issue and start discussing the improbability of the belief ’s possibility or the idea that this is just a thought. Again, for phobias and anxieties in which IU does not play a role, this may be appropriate; however, when IU is the sufferer’s core distortion, the therapist’s lack of empathy results in ignoring the sufferer’s problem as demonstrated in the below case.

A few years ago I was seeing a client with this fear—that her thoughts might harm or kill another. I agreed this was a possibility, but noted that her hit rate was so low, that it was hard for us to determine whether or not she actually had this power. I went on to suggest that we would work on killing people with thoughts in treatment, and that if someone died, I would urge her to continue with treatment, since a single death might be a coincidence. I added the stipulation that the individual would have to die within a reasonably short time of our attempt. I did agree that if she could kill three or four people in quick succession, treatment would be altered and we would contact the CIA, since they might have a special use for her. However, if this criterion was not reached and only one person died, treatment would continue and she would never know whether or not she was responsible for the death. In the first week the focus of treatment was the client’s father. He died at the end of the week! He had been sick, but he had not been on the verge of death.

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If the goal of treatment had been to prove that thoughts are harmless, what could I have said? How could I prove coincidence? The client stayed in treatment and recovered; she was willing to learn to cope with never knowing the potential power of her thoughts. Unlikely events can happen and OCD sufferers understand this better than most. How well do you understand your own fears and irrationalities? If you have an adolescent daughter, you will surely experience that night when she should be home at midnight, has not called and at 2:00 a.m. is still not answering her cell phone. The most likely reality is that she is not being raped and is not doing anything horrible, but do you find those odds comforting? Or are you willing to think about someone you love and then write on a piece of paper: “I want ‘x’ to die a horrible painful death?” How uncomfortable do you feel? Will you put the paper in your wallet and carry it for a week—after all, how often does anyone go through your wallet? If you have any discomfort or are not willing to do this, remember the difference between you and sufferer, is that you will forget this in an hour or so; for OCD sufferers, the agony of their fear is endless. It is important to acknowledge that intellectual knowledge is not emotional knowledge. All women know they can be raped, but most feel like it will not happen to them. One of the most traumatic difficulties of coping with rape is not only the act, but knowing that you live in a world where you really can be raped. In working with a victim, you are not going to try to reassure her by saying that getting raped twice is a low probability event. Again, OCD sufferers, in their own way, understand that the unlikely can really happen. Coping with uncertainty does not mean taking comfort in the fact that your FCs are unlikely. Coping with uncertainty means deciding how to live if your worst FCs come true. Our children might die. I could be diagnosed with cancer. I could lose an arm in a car accident. If any of these actually happen, our profession claims to be able to help victims cope with the reality. Coping with uncertainty means preparing to cope with any potential FCs the sufferer fears—no matter how much said consequences seem unlikely or do not bother you as the therapist. A second problem for the therapist is correctly identifying the FCs. There are two common mistakes the therapist can make. The first is assuming that the obsessive fear and neutralizing behavior define the FC. In Grayson (2003) I discuss Bill, who came to treatment with extensive rituals focusing on making sure the microwave was off. He would frequently check it and would be plagued by images of fire bursting forth from it. His therapist assumed that Bill was afraid of being responsible for the microwave starting a fire. He constructed a hierarchy for this and employed both imaginal and in vivo exposures along with response prevention. Bill failed to improve. The therapist asked me to consult on the case and what we found was that Bill’s FC was not causing a fire or burning the house down. It may have been at one time, but now Bill’s FC was that he would keep obsessing. When confronted with the microwave, he would actually obsess about whether he should use exposure and response prevention (E&RP) or rituals to try to stop obsessing. The treatment goal was modified to learning to live with the thoughts the same way he might live with the thoughts of a loved one who had recently died; that is, the thoughts would intrude, be unpleasant, might even interfere with functioning, but they would not be experienced as an obsession. Just as you can fail to ask enough questions to establish what a sufferer’s FCs are, you can also ask too many questions. Many cognitive therapists correctly use downward arrow to discover the core FCs—if x were to happen, then what? In Bill’s case, the temptation is to keep asking Bill what would happen if he did obsess, what would be the problem? Bill’s inability to come up with a significant disaster would not be proof for him that, in reality, he has nothing to worry about. His inability tells us that the pain/anxiety he feels and his belief that it needs to stop is the primary FC for treatment to focus upon. If earlier in this essay you felt too uncomfortable to write: “I want (insert your loved one’s name) to die a horrible and painful death,” and that piece of paper is not

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in your wallet, you should understand Bill. The fact your thoughts are not likely to influence reality and that no one regularly goes through your wallet does not rule your behavior. The last mistake a therapist can make is assuming the client and you have the same goals. In my book, Donna was a patient who did not like the idea that she or her family could die at any time (Grayson, 2003). Her therapist had her doing imaginal exposures in which she and her family were dying. Donna made no progress. Her therapist brought her to me and I asked Donna if she accepted the goal of treatment. She said she was not sure what I meant and I replied that the goal of therapy was for her live happily in a world where she or her family could die at any time. “I don’t want that!” she exclaimed. I asked her what the alternative was and she laughed, because she knew there was none. I told her that now we knew why treatment was not working. It was not because she had an impossibly resistant form of OCD; the problem was that she was getting the proper treatment, but had the wrong goal. She believed that E&RP was going to make her not worry about something that was possible. Now her goal was to learn how to live in a world where she might lose her loved ones and to begin to consider how she would try to go on. Note her E&RP was expanded to not only consider her FCs, but also a plan of how to survive disaster in the same way she would if her losses really did occur. Identifying the sufferer’s FCs that result from IU, planning an appropriate treatment, and making sure that he or she has taken the goal of learning to live with his or her particular uncertainties is the simply the first step. In the next section, some techniques to help further motivate sufferers will be discussed.

TECHNIQUES TO OBTAIN AND MAINTAIN COMPLIANCE Although E&RP is the primary treatment for OCD, sufferers will not receive the full benefit of treatment if they have not adopted the goal of learning to live with uncertainty. To foster and encourage compliance with this, our initial interventions are cognitively based, and include techniques from acceptance and commitment therapy (ACT). This article assumes that cognitivebehavior therapy (CBT) includes what we have learned from behavior therapy, cognitive therapy, and ACT, with each providing new ideas, improvements, and modifications to practice, and with none of them supplanting another. Socratic reasoning is one of the main approaches; however, the focus is not to convince the sufferer about the irrationality of IU and their rituals. Instead, this technique will be used to convince the sufferer that: (a) absolute certainty is impossible; (b) all of their rituals are insufficient to achieve their goals of obtaining absolute certainty; and (c) they are irrationally inconsistent in their attempts to achieve certainty. For example, consider a sufferer with contamination issues and FCs of dying. Using some of the example dialogues in the first section, we will be able to convince the sufferer to admit to the impossibility of obtaining certainty. The therapist’s next job is to find the flaws in their rituals; that is, in what ways can contamination find its way into the bodies of their loved ones and themselves despite their rituals? Have they successfully cleaned every surface and part of their body without contaminating anything else? Do they believe in civilized germs? Civilized germs are those that you can have on your body all day, but will not cause any problems before you go home. Once you arrive home, you apparently have some small window of time to cleanse yourself before they become active. Next comes the question of how consistent are they; that is, how successful are they at forcing others to follow their rules? Sometimes, the sufferer may claim to only be concerned about their responsibility, but you can counter with why is not it their responsibility to successfully convince those around them? And do they really believe those around them follow their rituals when they are not present? Why should not this be their responsibility? Finally, do they risk their lives in other ways, such as using a cell phone while driving? It is your job as the therapist to help them to acknowledge the inconsistency of engaging in this higher


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risk behavior compared to the probability of their contamination FCs. This dialogue provides an excellent opportunity to note that the severity of OCD problems is measured by consistency; that is, the more consistent you are, the more dysfunctional you are, whereas, the more inconsistent you are, the closer you are to “normal.” The goal is to have OCD fears and risks become like the non-OCD disasters or to put it another way: If you are not willing to be crazier to avoid danger, then it makes greater sense to work on giving up the pursuit of certainty. Because the saddest thing of all is that for all the ritualizing they may engage in, they never get the prize—certainty. The futility of obtaining absolute certainty is an important motivator, but it is not enough. Our treatment center’s evaluation process devotes time to identifying in great detail what the sufferer has lost to OCD. Simply knowing they have lost time, been late, or been embarrassed is not enough. You need to know the painful details of their losses; were they ever humiliated by their OCD behaviors? Have they lost jobs or destroyed relationships? Did they miss important events? Then explore the ways rituals interfere with loved ones. Ask parents or spouses if they love their family and would they do anything for them? When they say yes, gently tell them they are liars, because they will not give up their rituals for their loved ones. If the sufferer claims to be protecting them, point out the damage they are doing. Their children have a 1 in 4 chance of having OCD, and the sufferer’s behavior will serve as a guide as to whether OCD is something that can be beaten or not. Challenge them to become the kind of parent they want to be. The losses to OCD are critical to motivate clients, because behind every loss is what they can hope to gain if they embrace treatment. These techniques are not only the initial basis for obtaining a commitment to living with uncertainty; they also become an integral part of maintaining compliance and motivation during treatment. At our center we create scripts to put on CDs or MP3 players. You can think of scripts as imaginal exposure tapes that have matured. The scripts will include exposure material and FCs, but always in the form of: if you do “x,” “y” might happen and then we can go into detail of all of the potential horrors of “y.” The exposure is put in this form, because we are fostering exposure to IU. This tends to be more effective, because if you say “y” will happen when confronted by “x,” a small part of the sufferer believes it will not happen. When you say “y” might happen, this is more congruent with the sufferer’s fear of what might happen. But it is not enough for scripts to provide exposure. Throughout our treatment preparation, you are trying to help the individual to think differently about uncertainty: it’s inescapability, the possibility of coping and living with FCs that may result from exposure, and the losses that ritual attempts to eradicate uncertainty have resulted in. These need to be reinforced, because when a slip occurs, these ideas disappear. We try to have sufferers listen to their scripts as much as possible. After all, their OCD never rests, so why should treatment? The purpose of this is not to learn the content of the script; this learning takes place fairly quickly. Our clinical observation is that more time spent listening to a good script raises the odds that these thoughts will become the response to unplanned exposures. There is obviously more that could be said about using cognitive techniques and modifying their use to promote exposure and acceptance of uncertainty as opposed to attempting to neutralize fears through reassurance. When working with IU, the therapist needs to examine his or her techniques to make sure they are not accidentally feeding into ritualistic reassurance seeking.

TREATMENT RESISTANCE FACTORS Treatment resistance arises from a number of factors. Most of the time the term resistance implies the problem lies within the client; however, in the previous sections of this article, what might have seemed like treatment resistance factors were the result of therapist mistakes. Two such

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mistakes were failing to make living with uncertainty a joint treatment goal and/or trying to reduce uncertainty rather than promoting acceptance. Similarly, improper identification of the client’s FCs, either by not asking enough questions or by overzealous questioning, can also result in misguided treatment. In both cases, the sufferer’s difficulty progressing may appear to be some form of resistance rather than an improper case conceptualization. In this section, the focus turns to client factors.

Over-Valued Ideation (OVI) Over-valued ideation (OVI) was first identified and described by Foa (1979). Simply put, the sufferer with OVI believes in the reality of his or her fears. Although you may see this in any form of OCD, it is most commonly seen in hypochondriasis and body dysmorphic disorder (BDD). In these forms of OCD, OVI is the defining feature of these two diagnoses or to put it another way: the differences between these two OCD variants and “regular” OCD can be accounted for by the presence of OVI. When OVI is not present, sufferers, despite the intensity of their fears, rituals, and dysfunction, have a sense that their fear is irrational. For these sufferers, describing IU as the underlying core of OCD provides them with comfort, because it makes sense of their symptoms, for example, “I’m not crazy, but I am trying to have more certainty than possible . . . ” When OVI is present, the sufferer has no feeling that the symptoms are irrational. For hypochondriasis, the sufferer is sure they are suffering from an illness and is concerned that their physicians are missing the diagnosis. IU still plays a major role, since the sufferer is never sure they are well. With body dysmorphic disorder (BDD), the sufferer is certain that they are ugly in some way. Depending upon the presentation, IU plays a greater or lesser role. Attempts to neutralize their fear—that is, hide or fix the “disfigurement”—are never successful, though they may feel they get close. Although each of these manifestations of OCD has its own specific treatment requirements/ modifications, there are similarities they share that arise out of understanding the contributions of IU in their symptomatology. The therapist should neither confirm nor deny OVI; for example, the person with hypochondriasis should not be told he or she is not sick and the BDD sufferer will not be told anything about their appearance. The primary reason for this with hypochondriasis is twofold: (a) to promote the idea of coping with IU and (b) some hypochondriasis sufferers may have an illness or a malady that is not diagnosable, severe.or life-threatening, but still present. Similarly, a BDD sufferer’s description may have some accuracies, for example, there is a blemish or mark. Note how this is similar to how I worked with the woman who was afraid that her thoughts could kill people—I agreed they could. However, in the mind of the sufferers, their OVI seems to confirm the importance of pursuing the remedy. Rather than making the truth or accuracy of their assessments a treatment activity, the therapist needs to redefine the problem as to how much time is spent obsessing and ritualizing above and beyond any utility. Thus, the hypochondriac may be sick, but this does not require checking their blood pressure 15 times a day, or feeling a lump every 10 min to see if it has changed. For BDD, why keep looking in a mirror at home, since no one will see the sufferer and equally important, why would their “defect” have changed in 10 min? Sufferers will not disagree that their constant concern and attention plays a major role in ruining their lives. OVI suffers have two impossible demands: (1) I should not have to live with this (e.g., pain, discomfort, appearance); and (2) there should be a remedy for the situation. For hypochondriasis, there is a third demand: a doctor should be able to diagnose my problem. Given the failure of meeting these demands, the therapist’s job is to take the stance that E&RP is critical to coping. In response to the question, “what if these symptoms are real?” the answer is that this makes E&RP more important, not less. That is, the sufferer’s own experience has proven


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that what they are seeking is not likely to occur, so the most reasonable approach to living is learning how to successfully live with their worst fears being possible. Again, it is critical to successfully target their worst fear. For some sufferers’ with hypochondriasis it may be the possibility of death, for others it may simply be they do not want to obsess. For sufferers with OVI (and to some extent all sufferers), denial plays a role maintaining IU. At our center, denial is operationally defined as comparing reality to fantasy. For example, in the case of losing a loved one, denial is the individual’s comparison to their current life without their loved one and how much better life would be if their loved one were still present. Life might be better if this was true, but this is a fantasy that will never happen. Furthermore, if their loved one had not died, it is possible that something more terrible might have happened in the future. Of course, something more terrible in the future is not part of the fantasy comparison. In comparisons between real life and fantasy, fantasy always wins, because people do not include problems in their denial fantasies. When we compare reality with fantasy, we destroy and demean the moment. Imagine yourself with your lover at a beach by a small lake at sunset. Suppose you think to yourself: “if we were rich, we could be at a fabulous Caribbean resort by the ocean, watching a brilliant sunset with waiters bringing tropical drinks at the snap of our fingers.” It’s a nice thought, but if you allow yourself to be consumed by such fantasy wishes, the beauty of your very real lakeside sunset is now tarnished. If denial ruins lives, then why do so many persist in clinging to it? Rituals are supposed to provide some kind of relief, even if only for a few seconds. The relief provided by denial and rituals helps to avoid the loss that acceptance brings. For hypochondriasis, this translates to living with an undiagnosable illness; for BDD, living with an imperfect appearance. For the sufferer, the potential gains of acceptance cannot be considered without coping with the loss. Consider a gambler who has stopped gambling. Everyone around him congratulates him. Finally, he will get out of debt; his family life will come back together; he will not lose his house—it is a time of triumph. But he is sad. Why? Because he will never be rich. He’ll spend the rest of his life being just like everyone else. Again, this is his fantasy, because in reality, he probably never was going to be rich. Even in mourning, denial can feel better in the short run than acceptance. You can feel this difference in the words of denial versus acceptance. In denial, a person says, “Life would be better if my wife were still here.” In acceptance this becomes, “My wife is gone.” The sadness of the denial statement does not come close to the stark reality of moving toward acceptance. Mourning is the process of moving from fantasy to acceptance. You may always miss your loved one, but you can also relearn to enjoy life in the present. Mourning is not easy to go through, but to avoid the pain of mourning is to be trapped in a fantasy that will never materialize. Again, the goal is using E&RP and cognitive techniques to promote exposure and acceptance. In agreement with ACT, the goal is not to have a perfect present, but to live and appreciate the present that is. Obviously there is more that could be said about each of these problems, but suffice it to say there is a repertoire of techniques specifically suited to each of these manifestations.

Merged: When Is Comorbidity a Problem? In discussing treatment resistance we are constantly confronted with the problem of trying to determine whether the sufferer is simply unwilling to accept uncertainty, and work of treatment (i.e., a victim of denial) or are there significant issues that we have not identified. Again, at our center, the prime goal of treatment is deciding to learn to live with uncertainty and the primary treatment is E&RP enhanced by other CBT techniques. However, in the past few years (Grayson & Kirby, 2007, 2008; Rosenfeld, Grayson, Kirby, & Erwin, 2008), we have begun to identify a group of clients whose OCD issues cannot be treated without attention to their non-OCD issues.

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We have labeled these cases as “merged.” With regard to OCD, a problem is considered merged when the FCs of their OCD problems overlap with the FCs of other issues, problems, or diagnoses. This is not simply a case of comorbidity; instead, it represents a subset of comorbid cases. In the past we have noted, like everyone else, that some sufferers come to us with nothing but OCD; whereas, there are others who come to us with OCD and comorbid problems. The decision of what to treat first is simply a matter of which problem is interfering with life the most. Generally, treating their OCD first is the most efficacious approach, because the nature of the OCD symptoms often makes it impossible to seriously address the other issues. With merged cases, the decision is complicated by the nature of the non-OCD issues. The non-OCD issues have two lives: 1. Interfering with functioning outside of OCD symptomatology; 2. Comprising part of the FCs of the sufferer’s obsessions.

When this is true, we need to consider the sufferer’s broader belief system: What about accepting uncertainty makes no sense to him or her? To clarify this we’ll examine two different cases involving comorbidity of OCD and borderline personality disorder (BPD), one merged and the other not. In the unmerged case (Figure 1) the sufferer’s OCD focused upon contamination issues. In the merged case (Figure 2), the sufferer’s OCD focused upon jealousy issues. In the unmerged case, E&RP for contamination issues was straightforward. The client was made aware that she had both OCD and non-OCD issues and that treatment would eventually address both, but that we would start with her fear of contamination. The FC of contamination was the possibility of contracting AIDS; thus, the decision to confront her OCD meant accepting the possibility of contracting and living with AIDS. Figure 1 focuses upon her non-OCD borderline issues. If her husband received a bill addressed to his ex-wife, this would set off a chain of internal events. She would be concerned about his potential feelings of love for his ex-wife. For her, the possibility that he might still love his ex-wife made her feel worthless and unlovable. Her behavioral response was to verbally attack her husband and demand proof of his love. At some point in this chain, the combination of his apologies and her borderline fears of abandonment would lead to her accepting the apology and the problem would feel solved. If we wanted to represent her OCD, we would need a separate diagram. In the merged case, diagramed in Figure 2, the same stimulus, a bill to the ex-wife, triggers V’s OCD and non-OCD issues. Initially, her BPD was less obvious and her case was conceptualized as OCD jealousy. The implementation of treatment required V to stop searching for evidence of her husband’s love and to stop seeking reassurance. Accepting uncertainty meant living with the possibility that her husband might love his ex-wife more and her marriage was a sham. However, this did not take into account how jealousy played into her borderline belief system. In her borderline system, the possibility of his loving his ex-wife meant the possibility of V being worthless, unlovable, and ultimately doomed to loneliness. Initial standard treatment of OCD triggered these feelings, and, needless to say, a borderline crisis was precipitated. Treatment was not simply a question of which of these two problems should be addressed first. We had already found that focusing upon the OCD activated non-OCD FCs. Treating the BPD first was not an option, because she would become lost in the endless circle of ritualizing in an attempt to determine whether or not her husband loved her enough. The desire to have absolute certainty prevented her from having the resolution found in the case of unmerged OCD. Viewing this as a case of merged OCD changed our approach. As noted above, a core belief of our center’s approach to treatment is that a client cannot cooperate or agree with a treatment that he or she does not understand. Using Figures 1 and 2, V’s therapist explained to her how her OCD and non-OCD issues interacted. Once she understood the conceptualization, a collaborative treatment was possible. In the case of V, most of the initial work was on her BPD and, after a number of months, her OCD was addressed.


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Situation Getting a bill addressed to ex-wife

Automatic Thought What if he still loves her?

Cognitive Distortion Triggers Core Belief Labeling + Emotional Reasoning I feel threatened he doesn’t love me.

Compensatory Strategies Seek people who will never let you down. Attack inconsistencies in those who are supposed to love you.

Conditional Beliefs If I’m loved completely, I’m worthy. If not, I’m worthless and unlovable.

Behavior Attack husband verbally Demand proof he loves her Demand apology Etc.

Husband and Wife Responses Husband apologizes and tries to prove his love. V feels unloved and scared of abandonment wants reassurance and accepts apology feels close and loved and through emotional labeling (I feel loved) feels as if the problem is solved.

Core Beliefs I’m worthless. I’m unlovable.

History Family cultural belief of one-down. Father: frequent unpredictable verbal abuse. Mother: subjugated to father, worrier, didn’t protect children from father

FIGURE 1. V as “simple” borderline without merged OCD. Although our center has steadily been improving early identification of merged OCD, there are times when identification is not immediately possible. B, a young woman who came to the center with the fear she was gay, was a perfect example of this. Her rituals included the following: Extensive washing to get rid of the feeling that she was gay; avoiding any object that she associated with homosexuality, including magazines with women who appeared either provocative or masculine, books, and TV shows where such women appeared; and any object that she may have had gay thoughts in the presence of. She had tried E&RP at another center, but the goal of treatment had not been living with uncertainty, which, in her case, was living with the possibility that she was bisexual. The FCs she reported were being gay, which to her meant she would not be able to have the life she wanted. After being given the treatment rationale—essentially living with the possibility of having to learn to be a happy gay woman, she was enthusiastic about starting treatment.

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Grayson Situation Getting a bill addressed to ex-wife

Automatic Thought

Cognitive Distortion Triggers Core Belief

What if he still loves her?

Intolerance of Uncertainty As long as it is possible he doesn’t love me, I’m at risk because (see below);

Compensatory Strategies

Labeling + Emotional Reasoning I feel threatened he doesn’t love me.

Seek people who will never let you down. Attack inconsistencies in those who are supposed to love you.

Conditional Beliefs

Behavior Attack husband verbally Demand proof he loves her Demand apology Uncertainty never satisfied.

If I’m loved completely, I’m worthy. If not, I’m worthless and unlovable.

Core Beliefs I’m worthless. I’m unlovable.

History Family cultural belief of one-down. Father: frequent unpredictable verbal abuse. Mother: subjugated to father, worrier, didn’t protect children from father.

FIGURE 2. V as borderline with merged OCD.

She had come to treatment a very competent woman in a position of responsibility and power. She seemed to be the kind of client who would power her way through treatment. Instead, her response to the smallest exposures was overwhelming anxiety and hours of washing. Treatment went on like this for some time, while I continued to probe her history. After a few months, she revealed being traumatized by her mother’s sexual behavior throughout her childhood. She was very resistant to discussing these problems, let alone working on them. However, it became clear that the FCs she initially reported were incomplete. Besides what she had reported, a fear that she could not have the life she wanted, she believed that if she were gay it would mean that her mother’s behavior had had an effect upon her and that she would be as depraved as her mother. It would also mean that there were traumatic events in her life that would have to be more deeply examined.


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Thus, B was a case of OCD merged with posttraumatic stress disorder (PTSD). Exposure to her OCD obsessions triggered her non-OCD PTSD issues. Following this discovery, the relationship between her OCD and PTSD was explained to her (Figure 3). Again, E&RP could not be started, because it triggered PTSD issues she wanted to avoid. If we had simply attempted to address her PTSD, the result would have been severe anxiety and ritualizing. After she understood the merged nature of her problems, most of our efforts in treatment were spent on her on PTSD issues; her OCD was held in check with a kind of E&RP-lite. The latter was designed to help her have some control over OCD, but was not enough to make significant gains. At the end of 6 months, enough of her PTSD issues were addressed to permit us to implement a full E&RP program. Over the next 8 months we worked both on E&RP and PTSD issues. At my last contact with her, she had been having no significant problems for over a year.

Situation Seeing object “contaminated” homosexual content Cognitive Distortion Triggers Core Belief Automatic Thought What if I’m gay?

Compensatory Strategies Shower to clean off contamination.

Intolerance of Uncertainty It can’t be possible I’m contaminated. It can’t be possible I’m gay or perverted. It can’t be possible my past has affected me. Emotional Reasoning, All or None Thinking, Negative Predicting I feel anxious this proves I’m damaged I can never have the life I could have. My past evokes too much anxiety for me.

Conditional Beliefs

Behavior

I can’t cope with the anxiety I’m feeling If I’m gay, I’m a pervert If I’m a pervert, my past has affected me If this is true, I can never have what I want.

Avoid contact with contaminated object. Clean anything contaminant touched. Take shower until feelings go away. Other decontamination rituals.

Core Beliefs I’m damaged, worthless, and unlovable.

History Mother: inappropriate sexual behavior, self-centered, inconsistent, rejecting. Father: reliable compared to mother, judgmental, self-centered, being a good girl means knowing what he expects without being told.

FIGURE 3. OCD symptoms merged with PTSD.

Exposure & Response Prevention CBT for distortions, taking into account that almost all distortions will be subordinate to intolerance of uncertainty

CBT for OCD

Situation = Obsession Automatic Thoughts + Conditional Beliefs + Core Beliefs = Feared Consequences Compensatory Strategies = Neutralizing Rituals

FIGURE 4. Problem presentation: OCD and other problems.

Treatment of OCD or other issues will be independent. The decision which to treat first will be clinically made.

Appropriate Interventions Tailor CBT to distortions.

Appropriate CBT Strategies

Situation Automatic Thoughts Compensatory Strategies Conditional Beliefs Core Beliefs History

Treatment of OCD and other issues will be concurrent − treating them independently will fail.

Appropriate Interventions Tailor CBT to distortions.

Appropriate CBT Strategies

Situation Automatic Thoughts Compensatory Strategies Conditional Beliefs Core Beliefs History

Other Significant Diagnoses/Issues

Exposure & Response Prevention CBT for distortions, taking into account that almost all distortions will be subordinate to intolerance of uncertainty

CBT for OCD

Situation = Obsession Automatic Thoughts + Conditional Beliefs + Core Beliefs = Feared Consequences Compensatory Strategies = Neutralizing Rituals

OCD

Complete evaluation of individual’s problems

Complete evaluation of individual’s problems

OCD

CBT Case Conceptualization

CBT Case Conceptualization

Other Significant Diagnoses/Issues

Problem Presentation: OCD & Other Problems Merged

Problem Presentation: OCD & Other Problems Without Significant Overlap

14 Grayson


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Obviously, our center’s conceptualization of merged OCD can describe the interactions or lack thereof between any number of conditions, issues, or diagnoses. What makes OCD special is the core role of IU. Figure 4 presents the general model of unmerged and merged OCD. The problem with merged OCD is that IU leads to a feedback loop in which there is a negative synergy between OCD and non-OCD problems. Any attempt to address one activates the other. Our observations to date have found that the identification of merged OCD provides us with the knowledge of when E&RP needs to be augmented by additional treatment. The initial step is the simplest and easiest, helping the client to understand what he or she is going through. At this point, we do not have a treatment technology that would generalize to all clients other than a careful analysis of beliefs, distortions, and their interactions and then carefully designing a program to address these issues.

SUMMARY I continue to believe that IU is the core of most manifestations of OCD and related anxiety disorders (e.g., BDD, hypochondriasis, generalized anxiety disorder), and that a successful enduring treatment outcome is the result of the client accepting the goal of living with uncertainty combined with appropriate E&RP. It is a seemingly simple concept, enough to be dismissed or unexamined as a cliché. In this short article I have attempted to discuss some of the complexities arising from helping OCD sufferers to accept living with uncertainty. I want to note that this article does not address the growing research literature on IU that attempts to further dissect and understand the nature of this concept. I’m afraid that I will end as I began, with a cliché, one that characterizes all papers in psychology—there is a great deal of interaction and further research is necessary.

REFERENCES Foa, E. B. (1979). Failure in treating obsessive-compulsives. Behaviour Research and Therapy, 16, 391–399. Grayson, J. B. (2003). Freedom from obsessive compulsive disorder: A personalized recovery program for living with uncertainty. New York: Tarcher Penguin. Grayson, J. B., & Kirby, H. (2007, March). When do traditionally non-OCD issues need to be incorporated into exposure and response prevention for OCD? Paper presented at the 27th Annual Meeting of the Anxiety Disorders Association of America, St. Louis, MO. Grayson, J. B., & Kirby, H. P. (2008, March). Resistance and non-compliance in OCD: Poor excuses for poor case conceptualization or when and how to modify E&RP for OCD. Paper presented at the 28th Annual Meeting of the Anxiety Disorders Association of America, Savannah, GA. Rosenfeld, J., Grayson, J., Kirby, H., & Erwin, B. (2008, August). Avoiding the “whack-a-mole” treatment of complex and co-morbid OCD: Improving diagnosis and treatment planning. Panel presented at the 14th Annual Conference of the Obsessive Compulsive Foundation, Boston, MA. Acknowledgment. The author gratefully acknowledges the contributions and collaboration of his colleague, Harold Kirby, LCSW, BCD, who shares the credit for the development of this article’s ideas. Correspondence regarding this article should be directed to Jonathan B. Grayson, PhD, 1616 Walnut Street, Suite 714, Philadelphia, PA 19103. E-mail: [email protected]