Understanding OCD
What is OCD?
Obsessive compulsive disorder (OCD) is a condition characterized by repetitive intrusive thoughts, images, or urges or compulsive behaviors. The intrusive thoughts cause emotional distress, including worry or fear. Many people with OCD, but not all, might also experience compulsive behaviors that try to decrease that distress.
Common symptoms of OCD
Common OCD intrusive thoughts include:
- Intense worry about safety, such as not turning off the stove or locking the door.
- Significant worry about the cleanliness or contamination.
- A strong need for things to be symmetrical or in a certain order.
- Intrusive thoughts about you or a loved one getting hurt in the future.
- Intrusive thoughts about taboo topics, such as sexual or violent themes, that go against your morals or ethics.
Examples of common OCD compulsions include:
- Excessive checking (e.g., of door locks or appliances).
- Excessive cleaning or handwashing, to the point where your skin may become raw.
- Counting objects or rearranging things until it feels “right.”
- Repeating certain words or phrases in your head to “neutralize” the intrusive thoughts.
What Is DBT?
Defining Dialectical Behavior Therapy (DBT)
DBT is a type of therapy that was developed to help people cope with intense emotions, difficult relationships, and chronic suicidality – not OCD. Although DBT has since been adapted to be used with many different conditions and challenges, there is very little research testing traditional DBT for people who suffer from OCD alone.
Traditional DBT consists of two types of therapy that you attend concurrently:
- Weekly group skills training sessions where you learn and practice mental, behavioral, and emotional skills that will help you manage emotions and improve your relationships.
- Individual weekly therapy that complements your skills group.
Having said that, many therapists are trained in DBT and provide skills in individual therapy, without the group component. However, this option is not appropriate for everyone.
Core components of DBT
DBT has four content modules: Mindfulness, Interpersonal Effectiveness, Emotion Regulation, and Distress Tolerance. Each module contains educational components and skills to help you improve your ability to cope with emotions in a healthy way.
Importantly, DBT is centered around dialectics, which is the idea that two seemingly opposing thoughts can exist together at once. So, for example, you might feel nervous about starting a new job but also feel excited at the new opportunity – that is a dialectic. Another example is that DBT therapists balance the dialectic of accepting you as you are in the moment while also pushing you towards positive change.
What to expect during DBT sessions
DBT sessions can look very different depending on the setting and your therapist’s individual style.
DBT skills groups usually start with a mindfulness exercise lasting a few minutes. Then, the group reviews each member’s homework practice throughout the previous week. In homework review, each group member discusses their skills practice and can discuss with other group members any difficulties they encountered with using the skill. The bulk of the time is then devoted to learning a new skill in each group session. The practice of that week’s skill is assigned for homework.
Individual DBT therapy sessions usually start with a check-in and review of one’s emotional experience and relevant behaviors throughout the week. Your therapist would typically then move on to exploration and review of your practice of relevant skills related to your therapy goals.
How Does DBT Help Address OCD?
There is little research on the effectiveness of traditional DBT for OCD, However, some of the skills and ideas taught in DBT are relevant to OCD symptoms. Read on to learn more:
Distress tolerance techniques in DBT
Distress tolerance skills from DBT can help you cope with painful emotions. In OCD, these skills may help you tolerate the intense worry or fear related to your intrusive thoughts without engaging in a compulsion. Distress tolerance skills build your ability to tolerate emotions so that you can then respond to them in healthier ways.
One example of a distress tolerance skill that can help you with OCD is the STOP skill. The STOP skill is helpful when strong emotions lead us to do things we’d otherwise not want to do. This technique teaches you to stop, take a step back, and think mindfully about how you want to respond to this intense emotion. Learn about the STOP skill here.
If you’re one of the many people whose intense emotions can lead to obsessive thoughts or compulsive behaviors, you’ll want to know how to reduce the intensity of your emotions fast. The TIP skill teaches you how to change your body chemistry to help lessen negative emotions. Through changing your body temperature, intense exercise, and paced breathing, you can change your body’s response to upsetting situations and reduce the chances you’ll engage in compulsions.
Emotional regulation skills in DBT
Some people with OCD also have trouble regulating emotions, meaning that you have a hard time getting certain emotions under control. Many people with difficulty regulating emotions find that they’re more likely to have obsessions when an emotion is strong. In that situation, when an obsessive thought occurs, you might engage in unhelpful strategies to regulate that distress – like suppressing the thought or doing a compulsion – which gets in the way of managing obsessions and emotions in a healthier way.
There are many different emotion regulation skills. One such skill is “opposite action,” which can help you act in the opposite way that your compulsion urge is telling you. This can help you feel less controlled by those urges. Here’s a quick how-to:
Opposite Action
- Identify and name the emotion that you want to change.
- Check the facts of the situation to see if they fit your emotion.
- What is the event prompting your emotion?
- What are your interpretations, thoughts, and assumptions? Are you assuming a threat?
- Does your emotion or the intensity of it fit the facts of the situation?
- Identify and describe your action urges
- What is the compulsive behavior attached to those intrusive thoughts?
- Ask your wise mind – is acting on this emotion effective in this situation?
Then, if your emotion doesn’t fit the facts, or if acting on the emotion won’t be effective:
- Identify opposite actions to your action urges.
- If your action urge is to avoid or withdraw, the opposite action would be to engage, or to be around others.
- Act opposite ALL THE WAY to your action urges.
- Repeat acting opposite to your action urges until your emotion changes.
Accumulating Positive Emotions
Another way to enhance your emotion regulation is by accumulating positive emotions through pleasant experiences. In OCD, building up pleasant experiences can strengthen your emotional resilience. This means that when you do experience certain thoughts or urges, you are able to cope more effectively with them. Engaging in pleasant experiences each day can also help you recover from negative emotions more quickly.
To build pleasant experiences, think about one thing you can do each day that would be pleasant or enjoyable. Try to stay in the moment while doing those activities. Some examples are watching a movie, lying in the sun, eating an enjoyable meal, exercising, singing, arranging flowers, playing an instrument, doing a puzzle, petting an animal, reading a book. These types of activities will introduce more pleasant emotions into your day, helping to buffer you from unpleasant OCD symptoms.
Mindfulness skills in DBT
The practice of mindfulness helps you grow your ability to be nonjudgmental toward your own thoughts. In OCD, you might often feel controlled by the intensity of intrusive thoughts, or by what they mean to you. Mindfulness practices can help you feel less victimized by your intrusive thoughts. Mindfulness helps you see your thoughts as just thoughts, rather than reflexively assuming that they are the definite truth. Specific DBT mindfulness skills include observing and describing your thoughts, wise mind, and loving kindness meditation.
Comparing DBT with Other Therapies for OCD
Cognitive Behavioral Therapy (CBT)
CBT is a type of therapy that focuses on changing unhelpful thoughts, beliefs, and behaviors. CBT helps people with OCD change how you make meaning of and respond to your repetitive thoughts that cause fear and anxiety, and lead to compulsive behaviors. CBT for OCD helps you learn to respond to unwanted thoughts in a more helpful way.
Compared to control conditions, CBT interventions decrease OCD symptoms immediately after treatment and over time. CBT for OCD often focuses on a subtype of CBT therapy called Exposure and Response Prevention (ERP).
Exposure and Response Prevention (ERP)
ERP traces its roots back to 1966 and is considered a gold-standard treatment for OCD. In ERP, you and your therapist work together to create a list of your symptoms. Working with your therapist, you then intentionally provoke one of your obsessions at a manageable level of difficulty. Then you practice tolerating this feeling while resisting engaging in any compulsions.
So, for example, you might think, “My hands are extremely dirty, I need to clean them or something bad will happen,” and would then try to resist washing your hands.
ERP involves facing the feared thought or image without doing something to decrease your significant anxiety. Through ERP, the anxiety you feel lessens over time and obsessions become less frequent.
As mentioned above, CBT and ERP are gold-standard treatments for OCD and have been researched for many decades. Research supports these two treatments as the best for people seeking treatment for OCD. However, some specific DBT skills may be helpful for managing OCD symptoms, as described above.
The Role of Mindfulness in Managing OCD
Mindfulness and OCD
Mindfulness practices help you cultivate a nonjudgmental awareness of your thoughts. You might judge the intrusive thoughts as “bad,” which makes you try to suppress the thoughts. However, trying to suppress intrusive thoughts only makes them stronger. Sometimes these thoughts can be so distressing, they make you question your own morals and character.
OCD can make you feel “fused” to your thoughts, as if there is no distinction between the two. However, you are not your thoughts. Mindfulness skills can help you become less “hooked” by your thoughts, less pulled by how you interpret them.
Although mindfulness can be helpful for OCD, mindfulness skills are better integrated into other treatments rather than as a standalone intervention for OCD symptoms.
Integrating distraction techniques with ERP work
Distraction as a tool
Distraction skills are an important tool taught in DBT. They can help you create some distance between yourself and overwhelming negative emotions. Distraction can help you manage OCD symptoms, if done the right way. If a distraction causes you to avoid certain thoughts, feelings or situations related to your OCD, this probably means it is not the right kind of distraction for ERP.
However, distracting yourself with enjoyable, pleasant, or meaningful activities, are healthy tools for ERP. The goal of this type of focused distraction is to stay connected to a meaningful or pleasant activity as a way to cope with the intrusive thoughts that arise. When resisting an OCD urge in ERP, think about meaningful activities you could engage in as a focused distraction.
Self-Validation Techniques for Managing Intense Emotions in OCD
Recognizing and accepting emotions in OCD
It can be hard to get in touch with your emotions when obsessive thoughts fill your mind. When emotions are intense, you might not even know what emotion it is that you are feeling! One way to manage these emotional experiences is by figuring out what, exactly, it is that you are feeling.
Being aware of your emotions is the first step toward changing how you respond to them. It’s impossible to do something differently if you don’t know what it is that you want to change! Try to name the emotion you are feeling: is it disappointment, jealousy, worry? If this is tricky to figure out, try using a feelings wheel to help you name your emotion.
Remind yourself that pushing away thoughts or feelings will only make them want to take up more space. By naming your emotion, you are telling your emotion that it is OK to be present in this moment. Work toward accepting your emotions, even if you might wish they weren’t showing up in that way.
Techniques for self-validation in DBT for OCD
The content of obsessional thoughts can sometimes lead to judgments and worries about yourself. Many people with OCD engage in excessive reassurance-seeking as a way to reduce the emotions that come from these thoughts.
Instead of turning to others to provide reassurance, it may be helpful to instead validate your own emotions. For example, describe what you are thinking and feeling to yourself. You could say to yourself, “Right now I am feeling fearful. This emotion won’t last forever” as a way to validate your emotion and acknowledge that every emotion is temporary. This helps give those experiences truth, rather than pushing them down.
When you notice judgmental thoughts like “I shouldn’t have these thoughts” or “Having these thoughts means I’m a bad person,” look for ways in which it’s understandable that you are feeling the way you feeling. Some examples of self-validating phrases are:
- “This intrusive thought is really intense, it makes sense that I feel scared.”
- “I know these types of thoughts are difficult for me to experience, it’s understandable that I feel a bit unsettled or distressed!”
- “Of course I’m frustrated trying to get this task done because my OCD is getting in the way. No one likes being thwarted like that.”
Getting Started with DBT for OCD
Finding a qualified DBT therapist for OCD
If you are interested in DBT for OCD symptoms, finding a therapist who is trained in DBT is important. Please reach out to us at Manhattan Center for Cognitive Behavioral Therapy if you are looking to get some help.
Some of the above is based on excerpts from: Linehan, M. (2014). DBT Skills training manual. Guilford Publications
