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I am the founder of OCD Excellence and I have OCD. My OCD began as I entered my teens. I had no idea that there was a name for the strange stuff in my head, let alone treatment. Doing everything 4 times (or multiples thereof), associating bar codes with death, avoiding the colour red, amongst 100’s of other weird symptoms. After struggling along for 10 years I found CBT in my early 20’s and adapted it to my own OCD, courtesy of a kindly therapist who freely admitted she knew little about the condition. The lack of knowledge, help and support for people and families of people with OCD was all-pervasive. OCD treatment was a rare and elusive thing. After working in finance and PR, I gave up my career for lack of interest and a growing sense of something more meaningful. I volunteered for an anxiety charity whilst studying and establishing my own OCD treatment protocol. I found myself inundated with OCD enquiries on the helpline. The gold standard for treatment at the time was Seroxat. Being medication averse (common in OCD) my interest was peaked and I was determined to find a medication-free solution. So after some applied learning via the charity, I started my journey with a Masters in CBT. Over the last 15 years I split my time between New York and London, observing the cultural and professional differences in mental health care and OCD treatment. From the barely disguised psychoanalytical options in New York, to the barely functioning NHS CBT-based offering in the UK, there still exists an international need for highly specialist treatment for OCD. One that is based upon efficacy rather than medication, ineffectual protocols or a bureaucratic squeeze following another budget-serving whitepaper. My goal was to establish a gold standard for OCD treatment: the optimum combination of education, anxiety management and psycho-therapeutically robust techniques. It has been a lonely road. In the US they admire entrepreneurship & private practice but medication is king. In the UK, medication is met with open suspicion and the more socially-minded are known to spit on private practice. Any association between mental health and entrepreneurship is considered at best, unethical, at worst, illegal. Thank you NHS. The cumulative result of which is often life-threatening procrastination, low levels of self-responsibility and an unhelpful sense of entitlement against a continuing background of poor NHS provision. It’s a lose/lose. Sadly that hasn’t changed. But many other things have! The world is a dramatically different place relative to 2003 when I first practiced and ordinarily, in the case of other conditions, technological and medical innovations would be the only independent variables, but this isn’t necessarily the case with OCD — and for reasons you might least suspect. Who would have thought that one of the variables would be cultural or social? I have always conceptualised OCD as emotional hypersensitivity so that (thanks to Dr Jeffery Schwartz) I realised that people with OCD over-respond to emotional triggers across the board, and not just those with anxiety-provoking implications. People with OCD feel the full gamut of the emotional spectrum more acutely — anger, disappointment, rejection, you name it! I believe that the outcome of this biological anomaly is that people with OCD are highly sensitised to their environment. This can be witnessed in response to ‘new’ OCD obsessions fuelled by the media, e.g., the media’s concentration on paedophilia cases and the current media fascination with all things celebrity and most significantly, their relationships. These trends have coincided with an increased presentation of clients with responsibility paedophile concerns and also relationship neuroses. Hence, OCD evolves according to social and cultural emphases. The other aspect of our modern existence that has affected OCD is the dominance of the ‘self’, i.e., ‘selfies’, ‘self-awareness’, ‘self-marketing’, ‘self-absorption’, ‘self-analysis’, ‘self-diagnosis’….need I go on? It isn’t all bad. Who wouldn’t welcome the opportunity for people to take advantage of access to information so that they can make more informed decisions regarding their mental and physical healthcare? Obviously this is a huge step forward from the days of relying on the lucky dip of a single medical opinion from one’s local GP, who is often under pressure to meet timelines and patient quotas. Nevertheless, the OCD hours spent researching online, reading forums and just ‘thinking’ (I have clients that set aside days from work to ‘think’) are not conducive to recovery. Researching online is now in our ‘Top 10’ of compulsions across all sub-types. Which brings me to what else lurks online and this is the proliferation of treatments and interventions for OCD. Some of course, are helpful, but many aren’t and so online marketing rather than therapeutic skills, credentials and experience is king. Anyone with online marketing skills can present themselves as a viable therapeutic option, especially to those who are vulnerable and desperate for help. It is possible that options such as Chinese medicine, herbal remedies or hypnotherapy may have complementary benefits but it still remains that the only evidence-based intervention for OCD is cognitive behavioural therapy (CBT) and even then, we firmly believe that a sub-set of CBT, namely Rational Emotive Behaviour Therapy (REBT), is a much more robust intervention for OCD. We adjunct this with other approaches but REBT is an integral component of our protocol. In my own early search for help with OCD I fell foul of a lack of information and now, as a practitioner on the ‘other side’, I believe people are deluged with a confusing excess which detracts from finding effective therapy. All therapists run the gauntlet of others thinking this an easy commercial opportunity and so access to information can be risky!! Therapy can seem nebulous at the best of times but therapy for OCD requires a particular type of acuity. People with OCD are, by default, articulate and perspicacious so countering their complex, highly developed yet irrational obsessions requires sharp wits and proficiency. Hopefully in time, the quality and composition of OCD therapy will become standardised. Finally, our collective preoccupation with all things ‘comfortable’ including the categories of convenience, quick-fix and control. This is the big variable and it’s gathering speed and size. As a society we have moved further away from our grandparent’s notion that ‘life is difficult’ and closer towards the idea that ‘life needn’t be difficult for me if I can just find a way to get round it…….’, supported by the media and advertising industries who naturally know we are seduced by comfort and are in the business of selling us ideas, services and goods we want but are not necessarily good for us. I often think that Scott M Peck’s ‘The Road Less Travelled’ was a last ditch attempt in the 80’s to halt the downslide! And everyone bought it….but gave up anyway because life was just too hard! It isn’t rocket science that my single parent clients relapse less often than my teenage clients who have loving and very obliging parents. The single parent has to get better and the teenager doesn’t — well, not yet anyway. It’s a sad reflection that something we stand to lose is far more motivating. Concerned parents should always know that their child will only get better if they see the benefits of changing, or the penalties of not changing or both. If they see neither, then they aren’t ready to change. In summary, the world in many ways is working against people with OCD so that we therapists are often playing catch up. We, and society, like to believe we are proactive but instead we are reactive — to environmental stressors and influences outside our control. The idea of control, certainty, comfort — so integral to the core issues of OCD. I am aware that I deal with a condition that runs, nay sprints, towards these three ideals in a constantly changing, uncertain, chaotic world that lies to my clients. It tells them that the impossible is possible, their irrationality is rational and what’s more, loads of others would agree. I’m a therapist but really, I’m a dealer in answers and sometimes I have to limit these to no more than 5 per session…………. The big answer of course, is acceptance and the road less travelled, which is the cornerstone of what we do. Encouraging and supporting our clients to do the stuff of their nightmares. The basic premise isn’t rocket science — but shaping their detailed and complicated non-acceptance into acceptance requires conviction and guts! As I said, it’s a lonely road. Then, when they recover, there they are, ‘newly rational’, realising that the rest of the world is nuts. Ha! Join me on that road, I say.

The link between eating disorders & OCD has been documented since 1939. Kaye et al (2004)* concluded that 64% of eating disorders sufferers had at least one concurrent anxiety condition and 41% of these had OCD specifically. An article by Neziroglu & Sandler** differentiated between OCD and eating disorders for the purposes of diagnosis according to behavioural and motivational/obsessional criteria. I believe that a comprehensive diagnosis is more complicated and cannot be reduced to these two criteria alone. It will hinge on evaluating possible OCD according to the presenting food-related behaviours and obsessions together with past or present secondary OCD symptoms. In the case of food related symptoms, even assessing between OCD sub-types becomes critical since, if contamination OCD is suspected (avoiding certain 'contaminated' foods, e.g., oils or fats), then successful treatment would rely on differentiation between contamination (I will be contaminated) or a contamination-responsibility sub-type (I will contaminate others) which require different emphases. Neziroglu and Sandler differentiate between bulimia and anorexia in terms of an eating disorder but not with regard to their relationship with OCD. In my professional experience, bulimia can exist alongside OCD (co-morbid) but is more likely to be independent whereas anorexia can exist alongside OCD but is more likely to be interdependent. In the latter case, the OCD diagnosis is frequently marginalised or mistakenly overlooked as anorexia alone. In anorexia & bulimia, the individual’s obsessions revolve around body image, weight, dietary control and fears of rejection and behaviours revolve mainly around highly controlled eating and exercising. In the case of an OCD eating disorder (OCDED?) the obsessions are varied, as are the behaviours which may not be limited to controlling food. Clients who have been diagnosed with anorexia may actually have contamination issues regarding certain foods. As an example, a female client had an obsession regarding oils and fats triggered by a traumatic event at the dinner table as a child. Her OCD lead to her initially avoiding just oils in her diet but as her condition progressed she began to exclude ‘oil or fat-contaminated’ foods such as cheeses, meats, nuts, eggs, cream, butter, ice cream, etc. Unchecked, avoidant behaviours start with avoiding high risk factors and quickly encompass low and often, no risk factors. In any case, her weight loss was significant. When years of therapy targeting body image and self-worth had limited outcome, other food-unrelated OCD symptoms lead her to treatment for her OCD and her food avoidance was correctly assessed as an OCD symptom. Therapy specific to her obsession regarding oils and fats was effective in her long-standing recovery. This was contamination OCD. A male client had similarly been treated for an eating disorder when he reached a dangerously low BMI. When he expressed his fears that eating would ‘change him for the worse’ he faced 10 years of therapy tackling control, body image and self-worth. Eventually when a psychiatrist probed deeper, it was discovered that he was worried it would ‘change him in to a bad person’ – the feared change wasn’t physical. He was then mistakenly diagnosed with psychosis before a relative read an article about OCD describing this obsession regarding being a bad person as the basis of many OCD symptoms. This client feared he would change in to a bad person and do bad things to others. This was contamination/responsibility OCD. In my experience, other food control obsessions might be: 1.Avoiding food because of a traumatic event involving a person who is overweight - contamination 2. Controlling food during pregnancy – responsibility 3. Avoiding food or drink due to fears of being poisoned or drugged – contamination 4. Avoiding food or drink due to fears of vomiting, defecating or urinating - shame issues 5. Avoiding food without specific fears but because the habitual rituals of eating have become distressing and time consuming 6. Avoiding food because a person in the household is contaminated – contamination 7 Avoiding food due to hypochondria As I have always maintained, OCD is not a linear condition. It is complicated and often bizarre with a cross matrix of obsessions and compulsions, some of which may resemble other conditions. Not only that but other conditions can exist alongside and be independent or interdependent. The science of multi-diagnoses is improving, as are therapeutic approaches, nevertheless, a comprehensive assessment of an eating disorder should include an OCD screening for reasons stated above. In addition, an optimum assessment must also include other possible secondary sub-types of OCD as well as the food-specific obsessions and compulsions. It is possible, but rare, that OCD presents as just one obsession and behaviour. It is much more likely that the evidence for an OCD eating disorder assessment will lie with other past or previously presenting OCD symptoms, however covert. In short, to achieve much better outcomes, the science of assessing and treating co-occurring disorders away from the serial model must incorporate a wider and more comprehensive assessment at the outset narrowing to more specific and specialised treatment in the long-term. More about this later. *https://iocdf.org/expert-opinions/expert-opinion-eating-disorders-and-ocd/ **Kaye WH, Bulik CM, Thornton L, Barbarich N, Masters K, “Comorbidity of anxiety disorders with anorexia and bulimia nervosa.” Am J Psychiatry, 2004; 161 2215-2221. 2. Yaryura-Tobias JA, & Neziroglu F (1983). “Obsessive Compulsive Disorders Pathogenesis Diagnosis and Treatment.” New York Marcel Dekker

What’s the problem with reassurance and OCD? Any experienced OCD therapist will stress the importance of not reassuring as a priority, but why? One of the first-occurring and easiest means of dealing with anxiety is reassurance. This can be done instantly online or obtained quickly from our nearest and dearest. We have learnt since childhood that our parents offer immediate, soothing reassurance as is their practice. Not only was this one of our first coping mechanisms but it was freely given and parents are conditioned to emotionally rescue their children, believing that it was the one thing they could do well. It’s quick, cheap and seems like good parenting. However, in the case of OCD reassurance seeking, this is most certainly a compulsion and very quickly exacerbates the OCD and establishes poor coping skills. Access to various types of reassurance is easy these days and the predominant ones are: 1. Online reassurance: this can come in many forms. It tends to start with OCD forums. Clients with responsibility OCD will use the forums to see if they have OCD or are actually a bad person. HOCD sufferers will research for criteria to confirm they are or aren’t gay. ROCD means hours spent reading articles such as ‘How do I know I’m in love’ or ‘Are they the right person for me’ etc. Hypochondria/health OCD can find thousands of self-diagnostics online. The internet is a great resource but not when it is used compulsively Medical testing reassurance: for those who can brave being tested for their worst fears, getting tested is addictive. It seems at first as if it is a genuine health issue, followed by the idea that a test is definitive and can stop the worry. The sad truth is that the test will provide only short term relief before the urge to have another, and another accompanied by ‘It may not have been accurate’ or ‘it’s safer to be tested again’. Included in this category are visits to your doctor or specialist. 2. Verbal reassurance: this can come from all sources – family, partners, friends, colleagues. Not only is this unhelpful but it is very addictive, to the point where the sufferer needs the reassurance constantly. If others realise that they are doing the wrong thing then the sufferer can use creative ways in which to get it – asking cryptic questions, changing the theme and mostly, saying ‘this isn’t OCD, but……………’ 3. Self reassurance: in many ways, the most dangerous of all as this is entirely covert and can be continuous. A sufferer will reassure themselves, even during therapy and exposure work which can undermine the effectiveness. They can say to themselves, ‘I would never do that.’ Or ‘I’m not that type of person.’ They may have ritualistic chants or soothing messages. For a person with OCD, reassurance is discomfort avoidance whether obvious or concealed. It is a direct route to avoid anxiety and will work, at first. However, reassurance works like a whiskey to an alcoholic. At first, one or two a night is enough to feel good……….

In 2004 I first noticed my clients presenting with relationship obsessions. Naturally, OCD sub-types can have a cultural or sociological influence (HIV, CJD, paedophilia obsessions), but pathological obsessions about one’s relationship? Could this be a hitherto unrecognised sub-type? It didn't feature in the accepted assessments for OCD. And how might these obsessions differ from the growing cultural absorption with all things relationship? To answer the latter, the obsessions and compulsions of ROCD follow a similar, highly specific symptomology with often devastating impact upon the sufferer and their significant other. I happened to discuss my observations during a radio interview and there were floods of enquiries. From that point on, the incidence has consistently grown. All OCD is tough, often bizarre, yet this is the sub-type that most can relate to, albeit in a less obsessed sense. Most people have been preoccupied with their relationship but ROCD is an occupation – full time at that! ROCD is both aggressive and subtle. It is able to disguise itself and become habitual long before the sufferer realises. Then it is both triggered and reinforced daily by a media obsession with relationships – seemingly every magazine, internet article, TV show, movie, advertisement, blog and song. Furthermore, everyone else is discussing their relationships, and those of Brad & Angelina or Kim & Kanye, so that the unsuspecting sufferer takes some time to realise that they have a problem. Sadly this may be after they have spent years (and a few failed relationships) obsessing with friends and family who are all too keen to become involved. The ROCD sufferer may have no idea that their obsessions & compulsions have become pathological. Their behaviours may include mental ruminations that can occupy 90% of their waking hours, comparing their relationship to others, endless researching online whether they are ‘in love’ or their partner is right for them, seeking reassurance constantly from friends/family or their partner and incessant problem solving about whether to end their relationship or not. I always say that ROCD is ‘hidden in plain sight’. Despite hours of subjecting themselves and others to their quest for certainty, the ROCD sufferer may (or may not) eventually see the destructive, repetitive pattern or become so overwhelmed or depressed that they cannot function in their daily life. As a therapist, it appears to me that the unique characteristics of ROCD are likely to be: Ruminating (thinking) about your relationship for most of your waking hours (accompanied by intense anxiety) Asking yourself specific questions such as "Are they 'the one'?", "Is this really love that I'm feeling?", "Am I sexually attracted to them?", "Is there someone more suited to me out there?", "Am I missing out on life by being in a relationship?" Seeking reassurance from your partner about the questions above, often indirectly Confessing that you are thinking the above questions to partner, family or friends Reading prolifically about relationships and completing relationship questionnaires Discussing your relationship obsessively with others, particularly friends and family Comparing your relationship to others, particularly when out and about or socialising Scrutinising your partner, particularly their physical characteristics, personality or achievements Avoiding certain situations, for example, romantic movies or friends in successful relationships Sufferers of ROCD tend to present later for therapy since they tend not to identify their symptoms as a clinical condition. The world seems to be obsessed with relationships and the line between interested and obsessed isn't clear for most of us. By the time sufferers seek treatment, they are likely to have moderate or severe symptoms and may have already sabotaged one or more significant relationships. Relationship counselling may seem an obvious solution to a person obsessing about their relationship. However, if it is relationship OCD, OCD this would be an unhelpful strategy. A relationship therapist may not identify ROCD and may focus on the relationship and not the ROCD. Naturally, further investigation or analysis of a relationship is counter-productive and even detrimental to those with OCD. Even for therapists experienced in treating OCD, ROCD can be idiosyncratic: unlike other subtypes which rarely stand alone, relationship OCD can present without any other OCD symptoms. For those of use who regularly treat OCD, the symptoms are pronounced. Another complication is the fact that a partner or significant other may not accept the existence of ROCD or cannot cope with the nature, intensity or frequency of the obsessions which are essentially saying ‘I’m not sure I love you’ or ‘you may not be right for me’ or ‘I may not be right for you’. Even if a partner is ultimately empathetic and understanding, they can eventually become worn down by the unending deliberation and obvious distress of their loved one. A takes a robust relationship to weather the barrage of uncertainty generated by OCD. Like all manifestations of OCD, ROCD treatment must be based upon the premise that ROCD is bombarding the sufferer with questions that don’t need answering and problems that don’t need to be solved but it does require expertise to navigate the subtle ways in which this disorder can manifest and consistency in focusing the treatment away from relationships and towards OCD.

Mornings can be bad if you have OCD. Have you woken to a feeling of dread and acute anxiety whilst being battered by intrusive thoughts? You aren’t the only one and you might be surprised to hear that there may be a biological reason for this! When we conducted an informal survey of our client population, there was an approximate 50/50 split between finding the mornings or the evenings more difficult. Suffice to say, it is likely that up to 50% of people with OCD have experienced morning dread. Whatever stage of your recovery, it might be helpful to know that your morning struggle isn’t a sinister sign that something is very wrong. Instead, it may have more to do with endocrinology (study of hormones). It has been shown that there is a spike in cortisol levels during the first 30-45 minutes that you are awake. This phenomenon is intended to get you up and ready for the day and is known as the Cortisol Awakening Response or CAR*. This naturally occurring ‘stress hormone’ is released from your adrenals during stressful situations but also plays a role in other bodily functions such as blood pressure or immune function. In the morning it is intended to kickstart your daily activity but it can also kickstart your fight or flight response and can be pretty unwelcome, just after you’ve woken up. In those of us with long term anxiety conditions, OCD included, cortisol can exist in higher and more prolonged levels, contributing further to an anxiety over-response and a nasty sense of dread. So here are some suggestions for combatting this hormonal imbalance? Try not to lie there thinking. Get up as soon as you can and start getting on with your day. Resist that urge to put your head under the covers and avoid the world! Remember to use helpful self-talk, such as, ‘This is to be expected’, ‘I’m allowed to feel anxious in the morning’, ‘This will pass’, ‘This is likely to be a natural bodily response’. Accepting the anxiety is key because if you struggle or fight with it, things will only get worse. Use anxiety management techniques. No deep breaths. Instead, breathe in shallowly and a long breath out for a count of 8. Or try box breathing: in for 4, hold for 4, out for 4, hold for 4. Move your eyes gently to ease any obsessing and keep your focus short instead of staring off into the distance. Aim to eat something. I know it feels like the last thing you want to do but something with refined complex carbs like oatmeal or an oatmeal bar will help. You’d be surprised. Perhaps keep a healthy bar of oatmeal near the bed. Then you just have to reach out and take a bite! Write a morning plan the night before. You are unlikely to be able to write one when you are anxious so have one prepared. Make it a mixture of the things you need to do when you wake up, then you have it there, ready to go. Get out and get some daylight if you can. During these darker months it is especially important to get as much natural light as you can, so sleeping in until midday won’t be helpful for your mental health. Walking yourself or your dog will have a multitude of benefits. Put some favourite music on. Music can be a calming, mood enhancing influence. Make exercise a priority. Set time aside for morning exercise, either outside or inside with one of the many free YouTube videos. Exercise helps greatly with managing adrenalin and anxiety. It’s helpful for depression too. Meditate if you can. If you find it too tough when you are anxious, try a mindfulness task such as mindful walking, eating or colouring. Text or message a friend for support (but not for reassurance!). Research cortisol lowering natural supplements and speak to your nutritionist or doctor to see what might work for you. Perhaps think about investing in a radio alarm clock so that you wake up to something musical or interesting and less inwardly focused. If you suffer from the anxiey/OCD hangover, please let us know in the comments below. Which of the above works for you? Perhaps you have your own strategy? We'd love to know. *https://en.wikipedia.org/wiki/Cortisol_awakening_response

It is widely known that OCD consists of obsessions and compulsions. In more cases than not, obsessions are mental and covert (hidden) such as thoughts about harming others, health, contamination, relationships, sexuality or suffering. Whereas the compulsions are overt (physical, obvious, visible) such as repeating, checking, avoiding, cleaning, counting or praying. Pure O describes OCD where the compulsions aren’t visible. For this reason we see Pure O not so much as a sub-type, but as a symptom set, since people with Pure O can have the same obsessions as people with physical compulsions. Pure O compulsions might involve: Going over conversations mentally Trying to recall events just as they happened Trying to recall a memory perfectly Trying to order events according to a timeline Mentally counting Mentally neutralising (replacing a negative thought with a positive thought) Re-ordering thoughts Re-ordering words before speaking Mentally avoiding Mentally replacing thoughts Obsessively thinking (ruminating) Problem solving Analysing Evaluating Comparing There are some subtypes of OCD that are less likely to manifest with hidden compulsions. For example, contamination or health OCD are less likely to present with hidden compulsions since the first tends to involve cleaning, checking, disposing and avoiding and the second tends to involve bodily checking, online researching, tests & medical check-ups. There are however, some sub-types, such as relationship OCD, existential/metaphysical OCD or even HOCD, that might easily present with no physical symptoms. Since CBT or REBT doctrines are firmly based in behaviour work, it can be tough for therapists to treat people with Pure O. Helping a client intervene in their physical compulsions is possible but how do therapists intervene in mental rituals? Or thinking? There is no doubt that it is harder to help a client resist what is going on in their head. Part of the solution is for the therapist to identify the core belief that drives these symptoms and focus on developing new rational beliefs alongside some robust work on desensitisation. This often means that the therapist has to concentrate on habituating a client to themes, ideas and concepts rather than physical things. Not only that but it is possible to interrupt thoughts and mental rituals. It takes patience and repetition but it can be done. We never seek to ‘stop’ thoughts or get rid of them but we work on a client being able to tolerate them and not respond, physically or mentally. We often work with Pure O but what we need to do now is to raise awareness of the lesser known Pure O symptoms since mental rituals are every bit as disabling as physical ones. Sadly, sufferers are less likely to present for therapy, or present later, since it takes time for them to realise what they are dealing with. Physical symptoms are more obvious to a person and the people around them whereas mental symptoms are more private, ambiguous and often humiliating. It has been encouraging to see more social media interest in Pure O, particularly on our @ocdexcellence Instagram account. Also see my @healthhackers chat with Gemma Evans on 'Unwanted thoughts and mental compulsions - understanding ‘Pure O’.

OCD as a condition is very manipulative and darkly seductive. It draws clients inwards to focus on thoughts, feelings and emotions. As they withdraw mentally (and often physically) they become increasingly insular and narrowly focused. Spontaneity and natural characteristics melt away and these are replaced with what I’ve come to recognise as ‘the OCD stare’ – that glazed expression which allows the person to be present but entirely absent, locked in thoughts and constant analysis, evaluation and comparison. That process of relating every internal and external event to how it will impact upon them means that they can only be present in the physical sense, rarely the emotional or mental sense. The constant ‘How do I feel now?’, ‘What does that mean for me?’, ‘How do I get rid of this?’ and ‘If only I could be certain about…..’ leaves no room for much else. As the world continues around them, there they are, thinking, thinking and thinking. There are a number of tools and traits that OCD uses to facilitate and maintain this process. Cleverly, it finds existing traits and adapts them to be unhelpful and self-sabotaging. OCD particularly likes detail, feelings and strict rules. It can survive very nicely in the presence of all three, as follows: Detail: I always say ‘OCD gets you on the detail’. OCD ruminations, problem-solving, descriptions and questioning are very detailed. The more detail, the increased opportunity to generate more thoughts, more obsessions and more emotional discomfort. The more detail, the more ‘What if’s?’. The more detail, the more real the thoughts become. The more detail, the longer it takes to problem-solve and thereby keep clients on ‘lock down’. The more detail, the more difficult to describe the obsession to anyone else, making help less accessible. The more detail, the longer it takes to describe the obsession, prolonging the problem and delaying effective solutions. OCD uses detail to keep clients cruelly trapped in their head for years. Feelings: in the case of OCD, feelings are not one’s friend. OCD implies that feelings can and should be relied upon. Just look at all those other people using their feelings to make decisions, direct their lives and assure their safety? This isn’t true for OCD. They are not a good indicator of risk or safety and don’t serve clients well. The brain scans of people with OCD suggest that they are emotionally hypersensitive and this is perfect for OCD. Emotions and accompanying physical feelings can render clients rooted to the spot, unable to move or function. Added to that, OCD confuses thoughts with feelings, producing a horrid, nasty mess which a therapist has to untangle before work can begin. Clients will repeatedly say: ‘I don’t feel as if I can recover.’ (a thought not a feeling) ‘I feel as if I’m a bad person.’ (again, a thought not a feeling) ‘This feels real and not OCD.’ (never in my experience has this been the case) ‘I don’t feel I can trust myself.’ (a thought based on the need for certainty) ‘I feel as if this is genuinely dangerous.’ (anxiety or a thought or both) ‘I feel that this will make me worse.’ (a thought – effective therapy can trigger discomfort but the ‘severity’ of OCD is a long-term combination of many factors) However, feelings, correctly identified, are also not one’s enemy. Fighting, avoiding, and diminishing them doesn’t work consistently over time. They are at, worst, meaningless/habitual, and at best, interesting. Changing the relationship with feelings from engagement to observation is the way forward and dis-empowers the bully of OCD who is slapping clients round the face with them all day. Strict rules: OCD loves strict rules or beliefs. It works like a heat-seeking missile, the heat being those rules or beliefs which must be upheld at all costs. As soon as OCD finds a rule, it will use this to form the basis of an obsession. These rules are embedded in phrases such as, ‘I’m not that sort of person.’ Or ‘I would never do something like that.’ Or ‘What would people think of me if…..?’. Strict OCD rules can vary widely but they centre around the themes of being in control, being a good person, not suffering, having certainty, being approved of or to a lesser extent, other people behaving well. Generally, the stricter and more inflexible the rules, the more severe the OCD. Hence, in those cases where religion and morality become fused with OCD, progress can be slow and tough. Strict rules are a fertile bed for OCD to grow and regenerate itself as different guises of the same issue. Very handy.

Don't believe the movies, love is never a simple concept. Neither is OCD and the combination of both can be messy and unwieldy. There are three themes of love which crop up most frequently in relation to OCD and they are: 1. Do I love my partner? (Relationship OCD) 2. Loving others when you have OCD (OCD & relationships) 3. Loving yourself when you have OCD (self-acceptance) For those with relationship OCD, the nature and definition of love is an ever present preoccupation leading to obsession. It starts with the simple question, “Am I feeling love towards my partner?” and quickly becomes a neurotic quest for clarity against a cultural background of misinformation, romanticism, sentimentality, subjectivity, idealism and conjecture. Throw in some physiological responses such as racing heart, breathlessness and sexual attraction and a whole host of online surveys, relationship ‘experts’, well-meaning friends & family, books, videos & movies and you have the perfect environment for an OCD obsession. So much information and so little certainty. Working therapeutically with relationship OCD means shifting my clients’ focus away from an idealised ‘feeling’, or a definition, and towards an active, present & acceptance-based existence with another human being. There is much to be said for the phrase, “love isn’t a feeling, it’s a commitment to do loving things, day in and day out, to another person, regardless of feelings”. Love can’t be a goal but it can be part of a daily process towards building a meaningful connection with someone else. If ‘loving’ was a spectrum and at one end were the consistent, unconditional, unselfish acts of a parent towards their child, regardless of reciprocation and their own discomfort, and the other end was zero, then love towards a partner is likely to be a dynamic point between the two. This brings me to the idea of loving others when you have OCD. Outside of the struggle of those with relationship OCD, relationships can be tough when one person has OCD. Studies have shown that OCD can manifest practically as emotional hypersensitivity resulting in rejection, sadness, jealousy, anger, shame and anxiety being felt more acutely in those with OCD. This phenomenon tends to polarise communication with partners which can be either volatile and aggressive or suppressed and passive. Either of these extremes can be accompanied by chronic feelings of low self-worth and self-recrimination. All relationships, regardless of OCD, are challenging and once clients are managing their OCD, I encourage them to work on communication as a crucial foundation for their relationships. To investigate approaches like Non-Violent Communication (NVC) where they can learn to state their needs, observe & not participate in feelings and make solution-based requests to their partners. It also helps considerably if a chosen partner is willing to educate themselves about OCD, set appropriate boundaries and learn guidelines to avoid collusive behaviour. Finally, dealing well with relationship OCD or being in a relationship if you have OCD, is almost entirely dependent upon the most important love of your life. Your love for yourself. When you have OCD, loving yourself doesn’t come naturally but it is necessary if you want a fulfilling relationship with others and a functional future with OCD. As a therapist, I tend to see a timeline for self-acceptance which starts with accepting you have OCD, accepting you need to do something about it and coming out and sharing this with significant others. There are many more steps in this process and the commitment is more important than the order. I remember many years ago when I first started as a therapist, a journalist persuaded a reluctant me to commit to an interview about OCD. The result was a double page spread in the London Evening Standard about my own OCD and barely anything about my clinical opinions or work. Pre-Instagram, Facebook or blogging, the journalist rightly assumed that a human interest storyline was much more engaging to readers. Annoyed at the time, this one event shifted my self-acceptance forward by years. My very public ‘outing’, left me no choice other than to accept myself with OCD. Much later, OCD and I are life-long friends but I respect that this friendship will take time for many of my clients and it remains a major component of our OCD treatment. Worthwhile friendships are based upon unconditional compassion, care, understanding, listening, learning, failure and wiping the slate clean and starting again. During this Valentine’s week, in the midst of these difficult times, there is no more worthwhile and endearing love than that which you give yourself. Try it and see how the other loves in your life suddenly make so much more sense. With love to you...............

The jury is still deliberating whether health-related OCD obsessions are a sub-set of OCD or whether they are a separate condition altogether, i.e., Hypochondriasis. Suffice to say that health-related concerns present very frequently in our OCD client base, either as a primary or secondary concern. That is to say, for some, it is their major worry, whereas for others, it lurks in the background. What we have noticed, as therapists, is that health related fears tend to crop up even in those clients who have been managing their OCD well for extended periods. In these cases, there’s almost a sense of being caught out by the OCD! There are a number of reasons for the ‘stickiness’ of this set of worries. The first is that health concerns are consistently at the forefront of media attention, and as we’ve seen with COVID, can be relied upon to whip the most rational of folks into an emotional frenzy. The other probable reason is that health worries aren’t quite as bizarre as some OCD fears and sit only just this side of irrational. When it comes to health, the matter is highly subjective and emotive, and as a client once said, sometimes there is a fine line between cautious and crazy. I’ve seen articles that seek to differentiate between OCD and Hypochondriasis on the grounds that hypochondriacs won’t have other unrelated obsessions & compulsions. Well, we realise that hypochondriacs might not have OCD but the question is, do people with OCD have Hypochondriasis or are their health obsessions a sub-set of OCD? I’m personally leaning towards the latter but from a treatment perspective, the answer doesn’t necessarily matter. I would imagine that Hypochondriasis and health-related OCD fears would be similarly treated with CBT (Cognitive Behavioural Therapy) and a healthy (sorry!) dose of ERP, supplemented with ACT (Acceptance Commitment Therapy) and Mindfulness. In any case, this is one of those rare situations where the OCD symptoms are identical to those of another disorder and they are: Constant scanning for physical or mental symptoms, e.g., lumps, aches, pains, forgetfulness, etc. This may include standing in front of the mirror, counting freckles or lumps, daily breast exams, mental reviewing of previous situations, amongst other compulsions Catastrophising each new suspected health symptom so that there will be a noticeable leap to panic and dread, bypassing concern. We have noticed that there are recurring illness themes which often vary according to media concentration and are currently cancer (particularly throat, skin or brain tumours), Alzheimers/dementia, heart disease, COVID, stroke, HIV and sudden onset blindness Seeking reassurance is almost always a feature and this will take the form of expressing concerns to friends, family members or partners, often accompanied with questions relating to their own health, for example, ‘Have you ever felt dizzy, breathless, strange, nauseous, sore., etc? There may also be some mutual examination of physical symptoms leading to………. …extensive Googling of symptoms or case studies. This will be carried out by the person with OCD or, if they are too anxious to ‘learn the worst’, they may ask someone to Google for them Frequent visits to the doctor or specialist. Sadly these professionals are unlikely to realise that the concerns may be OCD-related. They will uphold their duty of care by taking the matter seriously, offering detailed explanation and analysis, suggesting tests and various alternative diagnoses, all of which will exacerbate the situation. Some doctors may sense the presence of a mental health imperative but only after repeated visits Outside the episodic health ‘crises’, there is likely to be ongoing health and safety hypervigilance which manifests as checking food ingredients, researching household chemicals, checking sell-by-dates, investing in numerous health supplements, following health regimes that gain media attention, etc. Avoiding likely sources of injury, illness or disease such as hospitals, doctor’s waiting rooms, adventure sports, public recreation facilities, the homeless, animals and pets, children and people who are unwell or suffering Avoiding films or TV shows about illness or disease, particularly life changing or terminal illness Excessive exercise or highly restrictive diets (Orthorexia) may feature and will deteriorate over time I remember a conversation with a client who had been coping impressively well for years with their OCD who called me regarding an ongoing health scare. They were awaiting the results of a test and wanted me to know that their news might be quite bleak. I was initially concerned for them. Then they said, ‘This time, it’s not OCD, this is a real fear! Health is a very real issue!’. Sure enough, their test was negative and it transpired that their family had suspected OCD throughout. Health is an issue of course, but in the case of Hypochondriasis, or OCD-related fears, it turns out that mental health is the real issue. See our recent Health OCD post on Instagram https://www.instagram.com/p/CYH_i4TM2fx/

OK, that's a mouthful! Psychotherapy can seem nebulous at the best of times but I have been reminded this week that we, as professionals, have to do our utmost to ensure it isn’t. Historically we can now, more than ever before, be precise about what is effective for OCD and what isn’t. Drawing on the considerable research to prove CBT is an effective therapy for OCD and BDD, the UK NICE (National Institute for Health and Clinical Excellence) guidelines clearly and unambiguously state: 1.5.2.8 When adults with OCD request forms of psychological therapy other than cognitive and/or behavioural therapies as a specific treatment for OCD (such as psychoanalysis, transactional analysis, hypnosis, marital/couple therapy) they should be informed that there is as yet no convincing evidence for a clinically important effect of these treatments. In other words, as therapists, we have a duty to inform clients that CBT is, as yet, the only scientifically proven intervention for OCD. Even across the Atlantic, the Practice Guidelines for the US National Institute of Mental Health, states that: ‘There are no controlled studies that demonstrate effectiveness of dynamic psychotherapy or psychoanalysis in dealing with the core symptoms of OCD.’ Yet the number of people with OCD considering or undergoing therapy other than CBT is considerable. I am of the opinion that 3rd generation acceptance-based therapies such as ACT (Acceptance Commitment Therapy) and mindfulness are an exception. They very much appear to have application and efficacy for OCD but the reason they aren’t mentioned in the guidelines is because they are somewhat recent, albeit in an applied sense. Mindfulness and relational frame theory (upon which ACT is based) are not recent, but their application as psychotherapeutic interventions has developed within the last 10 years. They haven’t had time to achieve scientific gravitas whereas psychoanalysis has been around for a century or more and hasn’t yet gained evidential support as a treatment for OCD or BDD. So what is the problem? Why are OCD clients not receiving CBT? Are therapists not telling clients that CBT is the scientific standard? Are therapists not aware themselves? Unlikely, since in the UK and US we cannot fail to be aware of NICE and NIMH guidelines. Are therapists relying on the fact that clients aren’t clear what treatment approach they are following or furthermore, what CBT should look like? So in an effort to set the record straight, what does CBT look like? 1. CBT for OCD should be a balanced mix of cognitive and behavioural work 2. Cognitive work is focused on cognitions or thought patterns which usually follow a model loosely based on an ABC framework. Initially the therapist will identify the triggers (obsessions) of your OCD, represented by ‘A’. These will then be used to formulate a belief represented by ‘B’ and identify your ‘C’s’ which are the consequences of holding your belief B. The C’s will consist of your OCD behaviours (compulsions), emotions and additional thoughts that arise from that trigger. The goal will be to adapt these ‘irrational’ beliefs to rational ones that are more flexible and realistic. This is the basis of the cognitive work and might not be as formal as this, depending upon the therapist’s style 3. Behaviour (ERP) work is the 'B' in REBT or CBT. This work should consist of exercises or tasks based around your triggers (A’s) that generate a challenging but not overwhelming level of anxiety whilst at the same time showing you ways in which to tolerate that anxiety leading to a gradual desensitisation to that trigger. It is called ERP (Exposure & Response Prevention) because it exposes you to triggers and anxiety and gradually helps you to stop responding emotionally or behaviourally. Another term is de-sensitisation. These tasks could be written, visual, physical, mental, imagery-based, etc. but they will have a common thread of generating anxiety. Much like Marmite, I'm not sure a client can be in the dark about behaviour work, i.e., if you’ve tried it, you’ll know! 4. There will be an emphasis upon homework. A characteristic of CBT will be the work you do between sessions to develop a self-help mindset and encourage you to be your own therapist. If the therapist doesn’t set homework this would be highly unusual. 5. CBT is skills-based. There should be a sense that you are learning skills to cope and use outside the session. Ideally you will be making notes during the session of homework plus techniques or new skills you will be trying to help you not respond to your thoughts and emotions. 6. CBT for OCD does not emphasize your history or childhood. Although some discussion of causation may be interesting, CBT will move quickly to your present environment and coping skills (or lack of them). Unlike psychoanalysis, CBT is directed towards the solution and not the problem. 7. CBT is 'directive' in style whereas psychoanalysis is 'non-directive'. In non-directive therapy, the client takes the lead and growth and outcome is expected to occur as a result of the client analysing, talking through or processing their issues. In directive therapy, the therapist takes the lead to teach specific skills, assign tasks and set agendas. My preferred form of CBT, REBT (rational emotive behaviour therapy)' is ‘active-directive’, in other words, the therapist directs the client to take action to manage their OCD. In all styles, the client should set their own goals. It isn’t difficult to see why a non-directive approach is not conducive to managing OCD - what happens when someone with OCD analyses, processes and discusses their OCD concerns? Enough said. It seems widely accepted that the future of psychotherapy will be empirically based and increasingly integrative and will combine approaches for best outcomes. However, this also implies that those very approaches need scientific grounding. I fully foresee a time when the recommended treatment options for OCD will include ACT and mindfulness alongside CBT or REBT as I do in our protocol (hopefully a little ahead of our time...) but until then, CBT for OCD please. At the very least………….

When my clients first arrive for therapy I’m under no illusion. At that stage they don’t really want therapy, coping skills or even their life to be more functional. What they would really like from me is certainty. So they say things like, ‘If only I could trust my mind………’, ‘I used to be certain and I don’t understand how that changed.’ And ‘I need to know this is OCD.’. This initial therapy phase is very predictable and reliable, unlike certainty. To be honest, I don’t even like that word and it’s generally associated with things that aren’t always pleasant, like death, DNA tests and doomsayer predictions. I also don’t like it because the apparent lack of it drives OCD forward to much bigger and more ominous things. I say apparent, because there is no such thing as certainty and therein lies the illusion of OCD. OCD relies very much on planting the idea that certainty is an option and it can be accessed via the right test, evidence, research, reassurance (from self/others) or very detailed thinking. This, like ‘fake news’, is fake certainty and the quest for it is very, very addictive. So, what do people with OCD think certainty looks like? Who cares! This is irrelevant, because for them, it’s all about how certainty feels. That feeling of certainty. That absence of the sense that something is wrong. The feeling of relief that they are, at last, feeling the right feelings. But they won’t be able to identify or articulate exactly what the feeling is and sadly it will last for minutes or hours. If they are lucky it might last for longer but it won’t be permanent. Part of the process of effective therapy is being able to firstly, identify the difference between feelings and thoughts, e.g., ‘I feel as if the world is against me’ is a thought whereas ‘I feel guilty’ is a feeling. And secondly, helping clients place far less importance upon feelings since they bear little relation to fact or actuality in the case of OCD (and apparently for those who don’t have OCD). Feelings are a poor criteria or basis for decision making. It is hard for clients to embrace this idea since we have become increasingly cerebral, culturally and sociologically. Thousands of books, articles, movies, social media and diary entries are written every day about the importance of feelings. I’ve read OCD forum posts where desperate people seek answers to questions such as, ‘I don’t feel love when I look at my partner so how do I know they are the one?’ (Relationship OCD). When someone replies, ‘If it feels wrong, it is wrong!’, I just think, ‘Good grief, that will set them back weeks in getting help or recovery’. Again, the idea of choice and the quest for certainty is the culprit. However badly behaved a child is, most parents don’t wake up in the morning and question why they aren’t feeling the love and if their child is right for them? Especially if it’s horrid weather and they have the flu. They enjoy positive feelings when they are there, but if they are not, they realise they must do the school run anyway. Fortunately, neuroscience is moving in a helpful direction. The work of neurologist Robert Burton points to the fact that certainty or the ‘feeling of knowing’ is a mental sensation and hence, chemical & biological. In the same way that the information processing around what we see isn’t based on what enters our eyes but is a highly processed signal that is partly determined by our expectations, the ‘feeling of knowing’ is independent of active, conscious reflection/reasoning and has little basis in fact or actuality. In his book, ‘On Being Certain’* he states that feelings of certainty stem from a primitive area of the brain and cannot be controlled by us. What this means for OCD is that those constant, frantic attempts to be certain are not only tortuous but a fruitless waste of time. This feeling cannot be controlled and it has nothing to do with what has happened, is happening or might happen – the big one. It also means that the search for certainty, reinforced by strong habitual behaviour, adds up to something very negative indeed. Moreover, as Burton also says, ‘Once firmly established, a neural network that links a thought and the feeling of correctness is not easily undone. An idea known to be wrong continues to feel correct”. Therefore a person with OCD isn’t easily dissuaded from the search for certainty and that’s where we, as therapists, come in. *On Being Certain by Robert A. Burton M.D, 2009 https://goo.gl/WBFQw4