Downloaded 93 times
More Related Content
Similar to Patricia Perrin - CBT for OCD Characterized Primarily By Intrusive Thoughts, Using ERP and ACT Approaches
![Updated Introduction to KSRWSP (1) [Autosaved].pptx](https://cdn.slidesharecdn.com/ss_thumbnails/updatedintroductiontoksrwsp1autosaved-251112115703-04fe2c13-thumbnail.jpg?width=640&height=640&fit=bounds)
Patricia Perrin - CBT for OCD Characterized Primarily By Intrusive Thoughts, Using ERP and ACT Approaches
- 1. CBT FOR OCDCHARACTERIZED PRIMARILY BY INTRUSIVE THOUGHTS, USING ERP AND ACT APPROACHES Renae M. Reinardy, Psy.D. Kathleen M. Rupertus, Psy.D. Patricia M. Perrin, Ph.D.
- 2. OVERVIEW OF OCDAND THEORY OF EXPOSURE AND RESPONSE PREVENTION Dr. Renae Reinardy
- 3. What are Obsessionsand Compulsions? Obsessions • Repetitive • Persistent • Thoughts, images, urges • Not pleasurable • Intrusive • Unwanted • Cause distress or anxiety Compulsions Rituals Repetitive behaviors Mental acts Feels driven to perform Neutralize “Fix” Avoid Not pleasurable
- 4. OCD goesfor shock value Misconception: “Because I thought it, it must be true” Thrives off of uncertainty: “How do I really know if…” Common themes: Violent, sexual, religious, and/or moral What Are Intrusive Thoughts?
- 5. Violent Obsessions Manifestations Harm to… Harmby… Obsessions Compulsions Self/ suicide Family members Strangers Infant/children Vulnerable Animals/pets Loss of control Sharp objects Car Someday I might I will I want to I have Impulses Images Avoidance Checking Mental review Fit it thoughts Neutralizing behaviors Reassurance seeking
- 6. Sexual Obsessions Manifestations ObsessionsCompulsions Strangers Family members Infants/children Animals/pets Sexual orientation Loss of control Staring Rape Sexual abuse Exposing Comments Uncomfortable Someday I might I will I want to I have Impulses Images Avoidance Checking Mental Review Testing Fit it thoughts Neutralizing behaviors Reassurance seeking
- 7. Religious Obsessions Manifestation ObsessionsCompulsions Making God angry Salvation Blasphemy Sexual Serving God Acting inappropriately Decision making Ultimate sin Sinful behavior Hell Devil If this then that Would I rather That was a sign God will punish me I am sinful because Blasphemous phrases Impulses Images Avoidance Repeating scripture Praying Fit it thoughts Neutralizing behaviors Mental review Reassurance seeking Excessive confessions Cleansing rituals Self-
- 8. Moral/Antisocial Obsessions Manifestations ObsessionsCompulsions Arson Theft Substance abuse Property damage “Bad person” Racist Rude Swearing Offending Someday I might I will I want to I have Impulses Images Avoidance Checking Fit it thoughts Mental review Neutralizing behaviors Reassurance seeking
- 9. • Thought-action fusion •If I think it, I will do it • Too much power to thoughts • Catastrophic thinking • Fear of loss of control and “snapping” • Probability overestimation • Intolerance of uncertainty • Possibility = Probability • Hyper-responsibility • I’d rather be safe than sorry • Perfectionism Cognitive Errors of Those with Primarily Obsessional OCD
- 10. • Guilty untilproven innocent • Selective attention to “facts” • I admired guy on front of magazine, I must be gay • Doubting even having OCD • Misinterpretation of bodily sensations • I think it moved • My body tensed up • I might have smiled during that thought More Cognitive Errors
- 11. CBT Model ofERP Obsessions • Trigger (Situation, thought) • Negative Appraisal (Meaning) • Anxiety/Discomfort • Urge to Neutralize (Ritualize) • Engage in Compulsion • Temporary Relief • Strengthening of Obsessions and Compulsions ERP • Trigger • Negative Appraisal • Anxiety/Discomfort • Urge to Neutralize • Exposure/Response Prevent. • Habituation of Anxiety/ Lasting Relief • Weakening of Association Between Obsessions and Compulsions
- 12. Fear Thermometer SUDS Rating Builda hierarchy 10 Freak out anxiety 9 Extreme anxiety 8 Strong anxiety 7 Pretty strong anxiety 6 Kind of strong anxiety 5 Moderate anxiety 4 Somewhat anxious 3 A little bit of anxiety 2 Tiny bit of anxiety 1 Calm
- 13. • Harm obsessions Buildan ERP Hierarchy SUDS 09/2016 SUDS 07/2016 Exercise 2 WST- Someday I will step on s/o toe 4 WST- Sometimes people hurt others 6 WST- Someday I will do something I regret 6-7 WST- I might cause slight harm to someone I care about 7 Hold a butter knife around others 8 WST- Trigger words (kill, stab)
- 14.
- 15. Overview of Acceptance andCommitment Therapy Dr. Kathleen Rupertus
- 16. Mindfulness-based behaviortherapy with roots in relational frame theory (RFT) Accept- willingness to allow the experience to be just as it is Choose your direction based on personal values Take Action in ways which reflect your values to make your life meaningful. “Life need not be determined by how much or how little anxiety you have.” Acceptance & Commitment Therapy
- 17. ACT Hexaflex Psychological Flexibility: Be present, openup, do what matters CONTACT WITH PRESENT MOMENT Be here now VALUES Know What Matters COMMITTED ACTION Do what it takes OBSERVING SELF (Self-as-Context) Pure Awareness ACCEPTANCE Open up DEFUSION Watch your thinking Source: Harris, R., Act Made Simple
- 18. Mindfulness and Acceptance acceptance defusion contact with the present moment self as context Commitment and Behavior Change committed action values contact with the present moment self as context 2 Functional Categories:
- 19. alternative toexperiential avoidance actively and intentionally embracing the experience fully and without defense willingness to accept the experience just as it is... “Are you willing to experience the anxiety if it means you get to have the good stuff?” Acceptance
- 20. mindfulness toreduce the literal quality of the thought weakens the tendency to treat the thought as what it refers to Techniques: repeatedly write or say out loud the thought/word “I’m having the thought/feeling/sensation…” observe the experience- “There’s thinking/feeling…” thank your mind for the thought What do “I” think about that? Defusion
- 21. ongoing non-judgmentalcontact with the experience it is impossible to not judge the goal is to get better at noticing judgments in order to reduce the literal quality of the thought weakens the tendency to treat the thought as what it refers to Contact with the Present Moment
- 22. self asa perspective, not an absolute Self as Context
- 23. What wouldyou be doing with your life if OCD was not in your way? Make decisions based on what deeply matters to you What truly matters in my life, beyond this moment/feeling/experience? How satisfied am I in those areas? In what ways are my struggles with anxiety interfering with doing what matters to me in my life? In what ways are my struggles with anxiety impacting my satisfaction in those areas? Values
- 24. … areon-going commitments with no end-point … serve as a compass Emotional outcomes are not values You follow values despite the emotional outcome Values
- 25. “It isabout doing, and doing in the direction of what you value and care about.” (Forsyth & Eifert, 2007) Action that is linked to a person’s chosen values Results in attainment of goals, behavior change, and behavioral and psychological flexibility Committed Action
- 26. Decrease experientialavoidance Increase flexible behavior Defusion ACT: “There’s thinking… That’s an interesting thought.” ERP: “That’s my OCD… what’s my best guess?” Similarities: ACT and ERP
- 27. ACT: Engagebecause of who you want to be (values) ERP: Engage because of what you want to get rid of (anxiety) ACT- Context of the thought is emphasized ERP- Content of the thought is emphasized ACT- Measures outcome based on moving in a valued direction ERP- Measures outcome based on SUDs reduction Differences: ACT and ERP
- 28. ACT: Greaterreliance on metaphor and experiential exercises ERP: Greater reliance on instructive psychoeducation ACT Focus on willingness to experience discomfort vs habituation Greater reliance on defusion (detach from meaning of thoughts) Differences: ACT and ERP
- 29. TREATMENT OF OCDUSING ERP and ACT Dr. Patricia Perrin
- 30. • Identify andchallenge cognitive errors/traps (probability overestimating, intolerance of uncertainty, giving too much importance to thoughts, hyper-responsibility, etc.) • In vivo and imaginal exposures • “Exposure to uncertainty”- to fearful thoughts, living with uncertainty that feared outcome may occur • Exposure to trigger words embedded with neutral words • Using exposure cues to address unpredictability and uncontrollability of intrusive thoughts • Use of an ACT metaphor to demonstrate acceptance, defusion, living a values based life, etc. Overview Of ERP and ACT Treatment Approaches for Intrusive Thoughts
- 31. Anxiety - Anxiety goesdown - Obsession comes back - Anxiety goes up higher - Checking again - Obsession comes back - Sense of loss of control - Anxiety goes up even higher Consequences of Checking (Freeston, 1998) CHECK!!! CHECK CHECK! CHECK!! CHECK!!!!
- 32. Anxiety -First time: anxietygoes up, stabilizes, comes down by itself - With practice, goes up less and comes down faster - When really good, trigger almost unnoticeable Exposure and Response Prevention (i.e., no checking) (Freeston, 1998)
- 33. Harming Obsessions: Leave knivesout/ Talk to spouse holding knife Drive by schoolyard with children playing Bathing / playing with baby alone Driving down road with potholes and not going back to check Sexual Obsessions: Seeing attractive women/men in gym locker rm. Looking at attractive women/men in magazines, catalogues, on TV, in movies Talking to attractive women/men at work/school Thinking about genitals of people in store, or at luncheon ERP: In Vivo Exposures
- 34. Scrupulous (Religious orMoral) Obsessions: • Praying an “imperfect” prayer, or a different prayer • Reading Bible w/o being sure about meaning • Going to communion while uncertain as to whether one has sinned and should go to confession • Eating a food you are not “perfectly sure” is Kosher • Touching paper that has been at school where students use bad words, fearing that it will make you use bad words • Turning in test although you glanced at a student’s paper and fear that you cheated ERP: In Vivo Exposures
- 35. • Imagining fearedevent: • Accident in which loved one injured • You standing over someone you stabbed with knife in your hand, and bloody scene • You saying blasphemous things • Imagining feared scenario with possible negative consequences for you (imaginal exposure script) ERP: Imaginal Exposures
- 36. We all livewith uncertainty: House could burn, flood while away – we still go out Car accidents happen – we still drive Unpredictable weather - we still go out OCD causes intolerance of uncertainty due to 1) giving too much importance to unchosen thought 2) misperception of responsibility/control 3) having intrusive thoughts of “the most inappropriate or awful thing you could do” (Baer, L., Imp of the Mind) Goal of treatment: Increase tolerance of uncertainty Exposure to Uncertainty - Rationale
- 37. Trigger: 1) Touchingdoor knob 2) Intrusive thought: I might stab a loved one. Ritual considered: 1) Wash hands 2) Reassure self that you would do no harm Response prevention: 1) Don’t wash hands 2) Don’t reassure self. Do exposure to uncertainty/don’t reassure: 1) Maybe I will get sick, maybe I won’t. No way to be sure. 2) Maybe I will harm loved one, maybe I won’t. Can’t be certain. Exposure to Uncertainty – Similarity to Exposure to Contamination Triggers
- 38. • Identify theanxiety inducing thought, e.g., “I could drown my new baby.”(common in postpartum OCD) • Establish that this is an undesirable thought, (ego-alien vs. ego- identified) that creates anxiety. • Do Exposure to Uncertainty: Say repeatedly (for example): • Maybe I do want to drown my new baby. • Maybe I don’t. • There’s no way to be sure. Exposure to Uncertainty (My Secret Weapon) - Format
- 39. • Identify anxiety/discomfortSUDS (subjective units of distress scale) level (0 -10) caused by saying or thinking these thoughts (i.e., by exposure to the intrusive thoughts of uncertainty). • Repeat statements to yourself until you notice your level drop to half of highest. • Be careful NOT to reassure yourself. • Think of Psychological Aikido – Using force of opponent (thought) against itself (Don’t engage thought. Let it go. Live with uncertainty.) Exposure to Uncertainty Techniques
- 40. • Harming Obsessions:Maybe I do want to stab him, may I don’t. There’s no way to be sure. Maybe I do want to molest children, maybe I don’t. I can’t be certain. • Sexual: Maybe I’m gay, maybe I’m not. I can’t really tell. (SO-OCD) Maybe I do want to have sex with my (family member), maybe I don’t. I really can’t be sure. Because I find that woman attractive, maybe that means I want to leave my wife, maybe it doesn’t, I really can’t be sure. (Relationship OCD) • Religious: Maybe I’m not a good Christian (Jew, Muslim, etc.). Maybe I am. No way to be sure. Maybe I want to curse God, maybe I don’t. No way to know. Exposure to Uncertainty - Techniques
- 41. • For triggerword “kill”, create list of rhyming or similar words, repeating list saying each word 1x, then 2x, then 3x. Rate anxiety after 2-3 rounds of reading each list, until anxiety to trigger word drops to half. Bill Bill Bill Bill Bill Bill Sill Sill Sill Sill Sill Sill Kill Kill Kill Kill Kill Kill Mill Mill Mill Mill Mill Mill Fill Fill Fill Fill Fill Fill Exposure to Trigger Word “Kill” Embedded with Neutral Words
- 42. DEVIL DAMN SUICIDE(Not Suicidal) Revel Sam Pesticide Disheveled Lamb Fireside Devil Damn Suicide Bevel Ham Coincide Level Tram Countryside Exposure to Trigger Words ‘Devil,’ ‘Damn’ and ‘Suicide’ Embedded with Neutral Words
- 43. • To addressunpredictability/uncontrollability of intrusive thought or image, which contributes to shock effect and anxiety/distress: • Choose cue word and think of thought/ image when you hear someone say it (e.g., weekend, today, car, store, start, etc.) • Choose cue time (e.g., every hour on the hour) • Set alarm on phone to cue doing an exposure • Choose cue activity (entering a room, hanging up the phone, stopping at red light) • Put trigger word in drawer you open frequently ERP: Imaginal Exposure to Address Unpredictability/ Uncontrollability of Intrusive Thoughts
- 44. • When cuedby word, time, alarm, activity, opening drawer, do one or more of the following: • Exposure to uncertainty • Bring intrusive image to mind • Exposure to word embedded in list of neutral words • Listen to imaginal exposure script ERP: Imaginal Exposure to Address Unpredictability/Uncontrollability of Intrusive Thoughts
- 45. ACT Hexaflex Psychological Flexibility: Be present, openup, do what matters CONTACT WITH PRESENT MOMENT Be here now VALUES Know What Matters COMMITTED ACTION Do what it takes OBSERVING SELF (Self-as-Context) Pure Awareness ACCEPTANCE Open up DEFUSION Watch your thinking Source: Harris, R., Act Made Simple
- 46. • Bus –Your life • Passengers – Some memories, thoughts, and emotions which you like. Some loud and unruly passengers, e.g., conditioned emotions, fearful thoughts, sensations, and urges that you experience in life, which you don’t like. • Driver – Whatever directs your life - Preferably you. • Sign on front of bus – Destination of bus: 1) “Struggle with OCD or Fearful Thoughts,” or 2) “Values Based Life” or “Value Mountain” ACT Metaphor: Passengers on the Bus or Driving Your Life Bus Sources: Hayes, S.C. Get Out of Your Mind & Into Your Life; Forsyth, J.P., and Eifert, G.H. The Mindfulness and Acceptance Workbook For Anxiety
- 47. • When strugglingto eliminate the source of anxiety, you spend a lot of time trying to get unruly passengers off the bus. You stop the bus, i.e., put values driven life on hold. • You turn around to try to quiet the loud, frightening passengers who say “don’t go there, it’s dangerous”. You do compulsions, (seek reassurance, avoid triggers for uncertainty and anxiety, do thought suppression). You miss your turn or let go of the steering wheel, and you lose your direction. You have lost control of the bus. • Result – you struggle because you cannot accept what is, anxious feelings are driving the bus, and result is you suffer. ACT Metaphor: Passengers on the Bus and the Nature of Struggle
- 48. • When youaccept that on the road to Value Mountain, you might feel anxious, or having troubling thoughts, you keep driving in your chosen direction. • You keep your eyes on the road to your destination, you control the steering wheel. You observe thoughts of fear or uncertainty, with detachment. Do not spend time or attention on them. Choose how to direct attention, in the present. • Result – Live values based life, w/o struggle, suffering. ACT Metaphor: Passengers on the Bus and the Nature of Acceptance
- 49. • Acceptance -Instead of avoidance, and doing compulsions, you develop a willingness to have the thoughts and feelings with you • Defusion – you notice thoughts and feelings with detachment, as if watching on movie screen • Awareness – you observe thoughts and feelings, without judgment, or struggling with them, or having to make them go away ACT Metaphor: Passengers on the Bus and the 6 Core Process of ACT
- 50. • Contact withPresent – You let go of worrying about what intrusive thoughts you had in past and how the anxiety they cause might affect future, and connect with the present • Values – you change sign on front of bus from “Struggle with OCD or Fearful Thoughts” to “Values Based Life,” or “Value Mountain” • Committed Action – you become the driver; you drive bus; you choose the direction of your life, with our without anxiety ACT Metaphor: Passengers on the Bus and the 6 Core Process of ACT
- 51. •Trigger Situation •Initial IntrusiveFearful Thought / Image •Emotional Reaction; Physical Symptoms •Additional Fearful Thoughts; Doubting Thoughts •Urges to Ritualize, Without Follow-Through •What This Would Say About the Person •Core Fears – Worst Case Scenarios Scripts for Imaginal Exposure
- 52. Renae M. Reinardy,Psy.D. Lakeside Center for Behavioral Change Fargo, North Dakota [email protected] www.lakesidecenter.org Contact Information
- 53. Kathleen M. Rupertus,Psy.D. The Anxiety and OCD Treatment Center Wilmington, Delaware [email protected] www.OCDdelaware.com Contact Information
- 54. Patricia M. Perrin,Ph.D. OCD and Anxiety Treatment Center of Houston Bellaire, Texas [email protected] www.ocdtherapyhouston.com Contact Information
Editor's Notes
- #2 Introduction of topics of each speaker… Please hold questions until the end when all speakers have finished, as your questions may be answered later in the talk.
- #5 When what you feel most is overwhelming fear… doubt… anger… guilt… powerlessness… resentment… or even despair. But it is precisely at those moments that you and your loved one will benefit most from remaining committed to the action of love while nurturing your own and your loved one’s growth throughout this unwelcome journey with OCD.
- #6 When what you feel most is overwhelming fear… doubt… anger… guilt… powerlessness… resentment… or even despair. But it is precisely at those moments that you and your loved one will benefit most from remaining committed to the action of love while nurturing your own and your loved one’s growth throughout this unwelcome journey with OCD.
- #7 When what you feel most is overwhelming fear… doubt… anger… guilt… powerlessness… resentment… or even despair. But it is precisely at those moments that you and your loved one will benefit most from remaining committed to the action of love while nurturing your own and your loved one’s growth throughout this unwelcome journey with OCD.
- #8 When what you feel most is overwhelming fear… doubt… anger… guilt… powerlessness… resentment… or even despair. But it is precisely at those moments that you and your loved one will benefit most from remaining committed to the action of love while nurturing your own and your loved one’s growth throughout this unwelcome journey with OCD.
- #9 When what you feel most is overwhelming fear… doubt… anger… guilt… powerlessness… resentment… or even despair. But it is precisely at those moments that you and your loved one will benefit most from remaining committed to the action of love while nurturing your own and your loved one’s growth throughout this unwelcome journey with OCD.
- #17 RFT- a psychological theory of human language- the building block of HL and higher cognition is relating- the human ability to create links between things… that language specifies not only the existence/strength of a link (as in associative learning) but also the type of relation as well as the dimension along which they are related Focuses on managing life, not anxiety.
- #18 Present moment- caught up in obsessive thinking vs attention to present moment Values- not aware of what I want from life/focus on OCD interferes with living valued life vs. I know what I value in life Committed action- I act on fear/OCD vs. I identify and act on things I value Self as Context- I am my Ts and Fs vs I recognize my Ts and Fs but I am distinctly separate Defusion- My Ts and fs are meaningful and important vs I see my Ts and Fs as experiences in my mind and body Acceptance- I struggle with my Ts and Fs and experiences vs I willingly allow my experiences to occur without struggling with them
- #19 Goal of all is to increase values-based action
- #20 ACCEPT- drop the rope- allows hands and feet to be free for something else- LIVING… envision family waiting as you tug o war… breathe it in, make room for it, allow thoughts to come and go, observe them compassionately without engaging with them
- #21 You are not your thoughts and feelings… You are the place and space in which your Ts and Fs play out Fusion- responding to words/images/experiences as if they’re the same as the actual life events they represent Defusion- techniques to change the way the individual interacts with or relates to thoughts by creating contexts for the thoughts (example- movie, wii) “I can’t touch it” to “I am having the thought that I can’t touch it.”… back up… notice… then touch it with the Ts and Fs in place
- #22 Describe the experience vs judge Notice judgments… “there’s judging”… and then return to the experience When you judge/evaluate, you’re > compelled to rid yourself of the T,F or E
- #23 Describe the experience I am separate from my Ts and Fs Can be aware of one’s flow of experiences without attachment in investment in which experiences occur (self as the movie screen/chess board)
- #24 Values are the “big picture.. What matters in the grand scheme” Personal Life Inventory Relationships- family, intimate, social Work and career Education, learning, personal growth Health Spirituality Community life, environment, nature Recreation and leisure
- #25 Eulogy/Epitaph- how did you live life on an on-going basis… anxiety vs valued directions ?
- #46 Present moment- caught up in obsessive thinking vs attention to present moment Values- not aware of what I want from life/focus on OCD interferes with living valued life vs. I know what I value in life Committed action- I act on fear/OCD vs. I identify and act on things I value Self as Context- I am my Ts and Fs vs I recognize my Ts and Fs but I am distinctly separate Defusion- My Ts and fs are meaningful and important vs I see my Ts and Fs as experiences in my mind and body Acceptance- I struggle with my Ts and Fs and experiences vs I willingly allow my experiences to occur without struggling with them