We’re featuring a series of eye-opening op-eds by clinicians and researchers who are enthusiastic about sharing what they’ve learned through years of working with patients and conducting research.
Today’s post is written by Dr. Marisa Mazza, Psy.D, a clinical psychologist and the founder of choicetherapyin San Francisco. Dr. Mazza has received extensive training in ERP, CBT, and ACT. She’s adjunct faculty at the University of San Francisco. And, as if she weren’t already busy enough, Dr. Mazza is also on the board of OCD SF Bay Area(the IOCDF’s local affiliate) and is Vice President of the San Francisco Bay Area Association for Contextual Behavioral Science, the local ACT chapter.
Dr. Mazza is one of the most dedicated clinicians we’ve met at nOCD, and we’re grateful to her for bringing her expertise to our blog. You can find more information about Dr. Mazza’s work here. Now here’s Dr. Mazza.
Laura is a 28-year-old female who came to see me for Pedophilia OCD (POCD). During our first meeting she was tearful and scared. She muttered the words, “I am scared that I may harm children one day. Are you going to report me to the police?”
Laura believed that she might harm children one day, and this led to her spending a significant amount of time avoiding children and thinking about her fear. She avoided taking buses and walking in or near parks and schools, adding extra time to her work commute. Laura’s OCD also had a negative impact on her relationship. Her boyfriend recently broke up with her because he was tired of her not being present when they were together. Laura was too busy worrying about whether or not he would be with her if he knew she had these thoughts.
As with most people with POCD, Laura’s fears were in direct conflict with her values, like being a loving and kind person. Laura cared deeply about helping vulnerable populations, which included children. When I asked Laura what she wanted in her life she was utterly confused. “I don’t know what my life will look like with these thoughts,” she told me. When I asked about what she wanted for her future, she responded with, “I used to want a family but now I don’t think I am capable of having children. I don’t know what I want.”
Laura spent most of her time trying to escape her thoughts and feelings. In trying to escape these internal experiences, she was also losing connection with who she was and what she wanted in her life. While the drive to engage in avoidance is completely normal, if we choose to avoid our experiences most of the time then we also start to disconnect from who we are and what is meaningful to us.
The gold standard treatment for OCD is Exposure and Response Prevention (ERP). Exposure means the person gradually faces what they are scared of or disgusted by. But exposures need to be paired with response prevention, because the goal is to learn how to face that fear or disgust without resorting to compulsions. For example, Laura’s fear was that she would one day become a pedophile. Her exposure exercises included practicing having thoughts like, I may harm children one day.Her response prevention included cutting back on her typical response: avoiding pictures of kids, parks, schools, and children’s stores. She would also typically avoid her own thoughts by focusing on her work, problem solving, and repeating things like “I am a good person.” So her ERP plan included intentionally bringing on the thought “I may harm children one day” while looking at pictures, being around children, and going to parks.
“If I’m not engaging in a compulsion, then what am I doing?”
This is a question many clients ask when practicing response prevention. It was through learning about Acceptance and Commitment Therapy (ACT) and mindfulness that I was able to answer it. ACT is also an evidence-based therapy for OCD that teaches people to be willing to experience whatever shows up while committing to behaviors that are in line with what is important to them. ACT therapists often use mindfulness to teach people how to be in the present moment rather than caught in thoughts of the future or past. As a psychologist, I integrate ACT and ERP to help people face their fears, learn how to re-connect with their values, and commit to what is important.
The more we fight, suppress, or control our thoughts and feelings, the more stuck we get. It’s similar to being stuck in quicksand. The natural instinct is to fight and get out, but that instinct keeps you stuck. The answer is to surrender, be still or make very slow movements. ACT teaches us how to have (rather than fight, ignore, or suppress) uncomfortable thoughts and feelings while committing to what is important. There’s a saying in ACT: If you don’t want it, you got it.
One way we do this is by teaching people how to change their relationship with feelings. Laura had a similar response to most of my clients, which is that once she was willing to connect with her feelings and the sensations in her body, she began noticing new things. Through the process of slowing down, in exposures and in her day-to-day life, she was able to notice how she felt. By allowing those uncomfortable experiences to exist, she began reconnecting with herself and her values.
Tips for Doing Exposure and Response Prevention
So how do we get into our bodies in order to reconnect with ourselves and live a life that is meaningful to us? Doing exposures is a great first step, but the way in which you do them is also important. Here are some tips:
- Pick an exposure that is challenging, but not overwhelming or too easy. Ask yourself which exposure exercise you are willing to do while experiencing whatever thoughts and feelings show up. This means you are willing to lean into or feel the feelings rather than engage in avoidance, compulsions, or distraction.
- Don’t rush through exposures. Pick an exposure you are willing to do slowly. The point of exposures is to help you connect to thoughts and feelings. If exposures are rushed, it’s difficult to notice them.
- Begin the exposure and notice what the OCD says. Let the thoughts flow through your mind as though they are trains at a train station slowly passing by. You can say the thoughts out loud as they come up if this helps.
- Notice what feelings or urges show up by following steps 5–9.
- Label the feeling (mad, sad, bored, scared, etc.)
- What is the sensation? (tightness, tingles, heaviness, lightness, etc.)
- Where exactly is it located? (stomach, chest, face, etc. )
- What color would it be? (red, black, grey, etc.)
- What form or shape does the sensation have? (a brick, a ball, a knot, a fist, etc.)
- See if you can welcome this sensation, by feeling it as much as you are willing. Perhaps that means feeling it fully or taking it more slowly, feeling the outer edges of the sensation.
- Notice how long you are willing to lean into the feeling. After a minute or so, go back to noticing the thoughts as they flow through. Then go back to feeling the sensation for a minute or so.
- Exposures are meant to be a feeling process, not a thinking process. You can acknowledge thoughts as they come up by saying or picturing the thought, but then shift your attention to the sensation in your body.
- Notice if anything gets in the way of connecting with the feeling or sensation in your body, and see if you can let go of that barrier and refocus on the sensation. Do this each and every time you get pulled away from the feeling.
- After doing this for a few minutes, notice any changes that naturally occur with the feelings or thoughts.
- In order to reinforce what you learn, you may want to ask yourself these questions post-exposure practice:
- What did I learn or notice about my own abilities from leaning into this experience and doing this exposure?
- What did I notice about the feelings or sensations?
- What did I notice about the thoughts? Are they true? Can I do more than what my mind says I am capable of?
Often times, people say they notice how fluid feelings can be. They are always changing. Just like waves in the ocean, sometimes the feelings are more powerful, like a big wave, and other times they are less powerful, like a smaller wave. Sometimes different types of feelings show up. Some people will even notice more than one feeling.
People tend to notice that when they allow themselves to have thoughts they’re less believable. They also often notice that thoughts are frequently wrong, or tend to be the result of catastrophizing. The more they believe the thought, the more powerful it becomes.
In terms of abilities, people often notice they are capable of having the uncomfortable feelings and thoughts while doing something that is meaningful to them. They are capable of not knowing the outcome in situations, but still taking a risk in the service of doing what is important. ACT teaches the application of these techniques in day-to-day life by slowing down, labeling how you feel, and allowing yourself to feel the sensations. Doing this even a couple times a day can be helpful.
The interesting thing about welcoming in uncomfortable thoughts is you begin to notice all your thoughts more. Some of them might even be helpful.
For example, Laura began to notice the thought “I miss working with kids and helping people.” She labeled this thought to be in line with her values, and chose to commit to working with children, even though it was scary. Laura’s openness to her internal experiences and her willingness to do scary things ultimately helped her live a genuine and meaningful life. When we ended therapy she was tutoring children with reading problems, was in a committed relationship, and was hopeful about having her own children one day.