What Jonathan Grayson, One Of The Most Famous OCD Therapists In The World, Didn’t Teach Me
In my last post about Jonathan Grayson, I reviewed how much I learned from him. One of the most important things I learned from Jonathan, which he learned after treating OCD for many decades, is the foundational role of agreeing to OCD treatment.
As I reviewed in the last post, for Jonathan, agreeing to treatment is not the same thing as learning about OCD, coming into therapy sessions, or even doing direct exposure and response prevention exercises. These are all part of OCD treatment but they’re not the same as agreeing to treatment.
What, then, is agreeing to treatment?
For Jonathan, agreeing to treatment is agreeing to learn to live with uncertainty.
In my last post, I described how important this insight is. In this post, I’m going to describe ways in which I think this insight isn’t as clear and comprehensive as it could be. That is, I’m going to explain why agreeing to learn to live with uncertainty is necessary but not sufficient when agreeing to OCD treatment. And I’ll elaborate on my alternative way of looking at what it means to agree to OCD treatment: Agreeing to OCD treatment means agreeing to learn to live with unwanted, uncontrollable, distracting, and painful internal experiences.
I’ll also describe how participating in exposure and response prevention (ERP) processes helps us practice living with these internal experiences and, if we practice enough, we’ll see for ourselves that we can handle these experiences, meaningfully engage in our lives even when we have these experiences, and that these experiences will go away all on their own.
Once we see that these internal experiences are safe and manageable, they won’t bother us as much and they’ll show up less frequently. That’s what most people are hoping for in OCD treatment: A life where they don’t have frequent, unwanted, uncontrollable, distracting, and painful internal experiences.
Necessary But Not Sufficient:
Let’s start by reviewing the phrase necessary but not sufficient. To show what this phrase means, consider squares and rectangles. If a shape is to be classified as a square, it must have four sides and four right angles. Having four sides and four right angles are necessary requirements for a shape to be classified as a square. That is, a shape can’t be a square if it doesn’t have four sides and four right angles.
But having four sides and four right angles isn’t sufficient for a shape to be classified as a square. Why not? Because a rectangle has four sides and four right angles and a rectangle is not the same thing as a square. What’s required, what properties are necessary and sufficient for a shape to be classified as a square? Four equal sides and four right angles. This is what’s meant by the phrase: All squares are rectangles but not all rectangles are squares.
So…what in the world does this have to do with OCD and agreeing to OCD treatment?
As I mentioned, learning to live with uncertainty is a necessary but not sufficient requirement of agreeing to treatment.
Why? Well, as Jonathan points out, and I agree with, in chapter two of his outstanding book, those of us with OCD, like everyone else, are entirely comfortable living with uncertainty regarding practically limitless subject areas.
What do Jonathan and I mean?
Jonathan and I are discussing the relationship between OCD, uncertainty, and possibility.
As I detailed in this post, the way OCD-related experiences around uncertainty show up is like this: If you can imagine a picture of an event in your head, then that event is possible. For an event to be possible doesn’t mean it’s likely. Only that the event could conceivably occur.
For instance, can you imagine a picture in your head of you not touching a light switch a certain number of times and, as a result of some kind of supernatural feature of the universe, someone in your family dies? Yes. You can. Does that mean it’s likely that the life of your loved one depends on you touching your light switch? Almost certainly not. But can you imagine a picture of your loved one dying because you didn’t touch the light switch in just the right way? Of course.
Can you imagine being eaten by a tiger in your front yard this evening? Sure. You know what your front yard looks like. You know what a tiger looks like. You know what you look like. You can imagine the tiger jumping on you and eating you. Is this event likely? Not at all. But you can see this possibility in your mind’s eye.
And one of the rules of OCD is that if you can imagine a picture of it in your head, then it could happen. It’s not hard to come up with a story of how a tiger ended up in your neighborhood. For example, a zoo truck was moving a tiger, it broke down near your house, the cage holding the tiger broke open, and now the tiger is on the loose. Those of us with OCD come up with stories like this all the time for our specific obsessions.
The Difference Between Living With Uncertainty And Living With Unwanted, Uncontrollable, Distracting and Painful Internal Experiences:
We can now connect the above discussion of OCD, uncertainty, and possibility with this important point: It’s very likely that most of you reading this are not anxious at all about the possibility that your family member will die because you didn’t touch the light switch right or that you’ll be eaten by a tiger later today. These events are possible. They’re conceivable. You can imagine a picture of the outcome in your mind. There’s uncertainty around these events actually occurring in reality. And yet, even though these events are possible, you don’t feel anxious.
What’s more, there are a practically limitless amount of possible but unlikely events that could occur – that might occur, that are uncertain – that don’t bother you at all.
You might be eaten by zombies, sucked into a blackhole, killed by terrorists, or struck by a meteorite (I’ve worked with clients whose lives were devastated by these possibilities). All of these events could happen. And, yet, they almost certainly don’t make you anxious.
So you’re already living with uncertainty and aren’t troubled by it at all. This begins to show why learning to live with uncertainty is necessary but not sufficient. This is why I prefer an alternative description of what it means to really agree to OCD treatment.
That alternative description is this:
Really agreeing to OCD treatment is not only learning to live with uncertainty (which you already do in countless ways). Really agreeing to OCD treatment is agreeing to learn to live with unwanted, uncontrollable, distracting, and painful internal experiences.
Jonathan gets close to identifying this distinction when he wrote,
“So, even if your obsessions and compulsions are literally attempts to avoid potential disaster, they are also attempts to make your anxiety stop” (p. 13).1
Notice the subtle shift of focus that Jonathan completes in this sentence. Jonathan has gone from focusing on learning to live with uncertainty (in contrast to completing a compulsion in an attempt to eliminate uncertainty about an unwanted event occurring) about a potential disaster actually occurring (which we do without difficulty in relationship to a practically limitless amount of uncertain possibilities) to learning to live with anxiety (in contrast to completing a compulsion in an attempt to eliminate unwanted thoughts and feelings).
It’s this subtle shift that I wish Jonathan had more fully elaborated on. It’s this subtle shift that Jonathan didn’t teach me enough about.
The Difference Between An Unwanted Event Actually Occurring And Getting Stuck With Unwanted, Uncontrollable, Distracting And Painful Internal Experiences:
One of the things those of us with OCD are afraid of is a disaster happening to us or the people or things we care about. But another thing those of us with OCD are afraid of is the unwanted, uncontrollable, distracting, and painful experiences of our internal world (e.g., intrusive thoughts, anxious feelings).
A disaster actually occurring is related to, but distinct from, getting stuck with unwanted, uncontrollable, distracting, and painful internal experiences related to the possibility of a disaster actually occurring.
This distinction is critically important.
Anyone who comes to see me for therapy recognizes that there’s something “off” about the way their anxiety is showing up relative to their primary obsessional content. If they didn’t think there was something off about their anxiety relative to their primary obsessional content, they wouldn’t come to see me. They’d be doing whatever they believe needs to be done to keep them safe.
To illustrate what I mean, imagine someone comes to see me with the primarily obsessional content of being struck by a meteorite (I’ve worked with a client who experienced this obsession).
This person isn’t coming to see me because they believe I’m going to, somehow, protect them from meteorites. Shielding people from meteorites isn’t a service I provide at my practice. Instead, they’re coming to see me because one part of them recognizes that the amount of time they spend thinking about meteorites, and the amount of anxiety they experience related to the possibility of being struck by a meteorite, is disproportional to their objective risk and damaging their life.
I can help them.
A big part of how I help them is to illuminate that they aren’t only scared of being hit by a meteorite. Those who come to see me are also afraid of becoming stuck with unwanted, uncontrollable, distracting and painful internal experiences.
You’ve probably noticed that I keep using this phrase unwanted, uncontrollable, distracting, and painful internal experiences. What does this phrase mean and why do I keep repeating it?
Those of us with OCD are very aware of the possibility of disasters occurring (even if we also “know” the risk is very low). But most people with OCD have not put words to the fact that, in addition to being scared of a disastrous event actually occurring, we’re also scared of the uncontrollability of our own internal world (whether or not the disastrous event actually occurs).
As I discuss here and here, a person whose primary obsessional content is being struck by a meteorite is aware that it’s always possible that they might be struck by a meteorite (even if it’s incredibly unlikely). It’s true that being hit by a meteorite is a frightening possibility. But, and this is the crucial point, although this person has never been struck by a meteorite and recognizes they almost certainly will never be struck by a meteorite, this person has been stuck with the unwanted, uncontrollable, distracting, and painful internal experiences about the possibility of being struck by a meteorite thousands of times.
Being stuck with those unwanted, uncontrollable, distracting, and painful internal experiences really has been distracting, really has been painful, and really has damaged their lives even though they’ve never actually been struck by a meteorite.
An Example Of The Difference Between An Unwanted Event Actually Occurring And Getting Stuck With Unwanted, Uncontrollable, Distracting And Painful Internal Experiences:
Imagine that the person that’s afraid of being struck by a meteorite has stopped leaving their home. They spend all their time in their basement. They believe that being in their basement will provide some protection from a meteorite and this belief reduces (but doesn’t eliminate) their anxiety related to the possibility of being struck by a meteorite.
Now further imagine that a friend asks this person to go to a baseball game. When this person even considers leaving the basement, they immediately experience increased anxiety. They also notice the thought: “If I leave the basement, I might be vulnerable to being struck by a meteorite.”
At this point, we again arrive at the central idea I’m emphasizing: Although this person knows that the chances of this person being struck by a meteorite if they go to the baseball game is very low (but not impossible), this person also knows that the chances that they’ll get stuck with the unwanted, uncontrollable, distracting, and painful thoughts and feelings about the possibility of being struck by a meteorite is almost a 100% guarantee.
How do they know it’s almost a 100% guarantee they’ll be stuck with these unwanted, uncontrollable, distracting, and painful thoughts and feelings? Because they’ve actually been stuck with these experiences thousands of times.
What this means is that even if they go to the baseball game and they aren’t struck by a meteorite, being at the baseball game is still going to be a miserable time for them. It won’t be miserable because they’re being hit by a meteorite. It will be miserable because they really are experiencing the unwanted, uncontrollable, distracting, and painful internal experiences.
Those internal experiences really do make it hard to focus. Those internal experiences really do hurt. Those internal experiences really do make it hard to meaningfully be present in the moment.
I’m sure you can imagine how hard it would be to watch and enjoy a baseball game if, the entire time, you're constantly noticing the thought “METEORITE MIGHT BE COMING” and feeling the flood of anxiety associated with this thought.
To illustrate this from a slightly different angle, imagine this person’s friend knows about their OCD. The friend might understandably say something like, “You’ll be OK. You won’t get hit by a meteorite.” (That’s providing reassurance, but we won’t worry about that now).
Of course, it’s almost certainly true that there will be no meteorite strike. But, imagine if the friend said something else. Imagine if the friend said, “You’ll be OK. You won’t get stuck with the unwanted, uncontrollable, distracting, and painful internal experiences.” This idea, the idea that the OCD sufferer won’t get stuck with the unwanted, uncontrollable, distracting, and painful internal experiences, is almost certainly false.
The Uncontrollability Of Our Internal World:
It’s this way of looking at OCD that contributes to my supporting my clients in understanding that, yes, one of the things they’re afraid of is their obsessional fear actually occurring in reality. But another thing they’re afraid of, and oftentimes even more afraid of (although they typically don’t yet have the words for it), is the uncontrollability of their internal world.
Think about how scary that is.
Think about how scary it is to really experience the uncontrollability of your internal world.
Of course, in a way, the uncontrollability of our internal world is related to the uncontrollability of the external world (e.g., we really don’t have control of being hit by a meteorite). Still, we recognize that the amount of thoughts, and the intensity of the feelings, we experience related to this unlikely external risk is disproportional. What we also know, though, is that even if the risk of the external event is low, the likelihood that we once again experience the uncontrollability of our internal world is practically guaranteed.
In other words, and to repeat: How many times has the person actually been harmed by a meteorite? Never. But how many times has the person actually been harmed by the uncontrollability of their internal world? Thousands of times.
Let’s reinforce this idea one more time from another angle.
Imagine I’m working with Andrew regarding his fear of flying. Andrew experiences tremendous anxiety when even thinking about getting on a plane. For years, he’s been able to avoid flying. But, he recently obtained a promotion at his job that will require him to fly. He doesn’t want to give up the opportunities of his promotion. So, he decides he should come see me to try and do something about his anxiety.
Andrew: “William, I know I shouldn’t be so anxious about flying. Anytime I even think about flying, I get images of the plane crashing and me dying. It’s so scary. I’ve read the statistics on flight safety a million times. I know flying is way safer than driving. And I don’t get anxious at all when I drive. But no matter how many times I review the stats on flying, nothing makes my anxiety go away. There’s something wrong with my anxiety! Can you help me?”
I can help Andrew. Part of helping him is supporting him in realizing that he isn’t only afraid of dying in a plane crash. He’s also afraid of getting stuck with unwanted, controllable, distracting, and painful internal experiences even if he doesn’t die in a plane crash.
Part of how I will support Andrew in becoming aware of this sounds something like this:
William: “Andrew, I’m so sorry you’re having to go through these experiences. That sounds so scary and so painful. Also, you mentioned that you think there’s something wrong with your anxiety. I’m not sure I see it that way. In fact, I suspect your anxiety is showing up exactly how it should.”
Andrew: “What do you mean? You think it’s dangerous to fly? I told you: I’ve read the statistics on flight safety. It’s way safer than driving. I don’t get anxious when I drive. I get anxious when I fly. If it was really dangerous to fly, then everyone would get anxious when they fly. But lots of people don’t get anxious at all about flying.”
William: “Right. You’ve read the statistics on flight safety and you know that, from this statistical point of view, it’s far more dangerous to drive your car than it is to fly. And from that information you understandably conclude that if your anxiety was responding accurately to this statistical information, then you’d experience more anxiety when driving than when flying. But that’s not how your anxiety shows up. You experience basically no anxiety while driving and overwhelming anxiety while flying or even thinking about flying. And this is what leads you to believe there’s something wrong with your anxiety.”
Andrew: “Spot on. That’s what I mean. So why did you tell me that you think my anxiety is showing up exactly how it should?”
William: “That’s an understandable question. And, once we review some other ways of thinking about your anxiety, I think you’ll understand what I mean. For starters, let’s make sure I’m understanding some basic details about your experiences. My understanding is that over the past five years you’ve only rarely been on a plane – like that time you told me you got on a flight so you could get to your brother’s wedding.
Andrew: “Yeah, that’s right.”
William: “And what has it been like for you each of those handful of times that you flew over the past five years?”
Andrew: “Terrible. Each time, weeks before my flight, I was feeling anxious, being very distracted at work, losing sleep. Driving to the airport was awful. Being at the airport was miserable. Getting on the plane was torture.”
William: “You had all these thoughts about what might happen on the flight and it felt very scary and painful for you.”
Andrew: “Yes, exactly.”
William: “So, if I’m understanding you close to right, although you never died in a plane crash on any of these flights, you really did go through tremendously distracting and painful internal experiences before and during these flights.”
Andrew: “Yes, it was so, so painful.”
William: “Let’s take stock: You’ve told me that over the past five years, you’ve taken a handful of flights and, before and during each of these flights, it was a terribly distracting and painful experience for you. Is that right?”
Andrew: “Yes. Exactly.”
William: “And is it also correct, then, that you’re expecting your next flight experience to be similar to these past flight experiences?”
Andrew: “Yeah.”
William: “Got it. I think what you’re telling me is that although you “know” from your reading of flight safety statistics that you almost certainly won’t die in a plane crash, you also know from your direct lived experiences that it’s going to be very painful to be you before and during the flight.”
Andrew: “Yep, that’s right.”
William: “Now we can see what I mean, Andrew. How do you think I would expect you to feel if you knew you were about to go through a terribly painful experience?”
Andrew: “What do you mean, how would I feel if I knew I was about to go through a terribly painful experience?”
William: “I mean, if you were confident that you were about to have a very distracting, very painful set of experiences, do you think you’d feel happy about that?”
Andrew: “No, of course not.”
William: “How come you say of course not?”
Andrew: “Well, if I knew I was about to be very distracted and in a lot of pain, I wouldn’t feel happy. I’d probably be bracing myself. I’d be scared.”
William: “I think you’re telling me that if you confidently expected that you’re soon going to be in a large amount of pain, that you’d feel anxious.”
Andrew: “Yeah. Of course. Probably everyone would feel like that if they believed they were going to go through a very painful experience.”
William: “I agree. This is how come I mentioned that I believe your anxiety is showing up like it should.
You rightfully pointed out that the chances of you dying in a plane crash are far smaller than the chances of you dying in a car crash. You also pointed out that you don’t get anxious at all about driving your car but you feel very anxious about flying.
So, when you wake up on a typical day and know that you’ll be driving to work, you’re not expecting to have a painful experience while driving your car. And you’re not expecting to have a painful experience while driving your car because you never or almost never have a painful experience while driving your car. All this even though you know that driving a car is a risk – and a much higher risk than flying.
On the other hand, over the past five years, every time you’ve had a flight, you’ve been terribly distracted and anxious before and after the flight. Those experiences have been very painful. So you’re confidently expecting it’s going to be another painful experience next time you have a flight.
All of this is to say that one of the things you’re afraid of is dying in a plane crash. But you’re also afraid of having a set of unwanted, uncontrollable, distracting, and painful internal experiences.
Although you’ve never been in a plane crash, you’ve had unwanted, uncontrollable, distracting, and painful internal experiences basically every time you’ve flown. These experiences really have been distracting, really have been deeply painful, and you’re confidently expecting these kinds of experiences to happen again before and during your next flight. So even if your plane doesn’t crash, you’re probably still going to have those kinds of painful internal experiences before and during your next flight.”
Andrew: “Oh. So I’m afraid of a plane crash. But I’m also afraid of what it’s going to be like to be me before and during the flight, even if my plane doesn’t crash.”
William: “Right. Because even though, as you already pointed out, the chances of your plane crashing are close to zero, the chances of you having unwanted, uncontrollable, distracting, and painful internal experiences before and during the flight are almost guaranteed. Those experiences really do distract you, really do hurt to live with, and really do get in the way of you living life the way you’d like. What I can help you do is regain control over your internal experiences even though I won't change anything about the safety of your plane flights.”
Even if Andrew realizes that part of what he’s afraid of is his unwanted, uncontrollable, distracting, and painful internal experiences, that doesn’t mean his fear of flying is going to quickly disappear. Understanding what he’s experiencing and changing what he’s experiencing aren’t the same thing. Just like understanding how to lose weight (e.g., knowing the need to maintain a caloric deficit via diet and exercise) is not the same thing as actually dieting and exercising to lose weight.
How Does ERP Help Us Learn To Live With Unwanted, Uncontrollable, Distracting And Painful Internal Experiences:
This is where exposure and response prevention treatment (ERP) treatment comes in. In ERP, we aren’t changing anything about meteorites or plane safety. Instead, in ERP, we’re changing our relationship to our unwanted, uncontrollable, distracting, and painful internal world.
Before people begin OCD treatment with me, they typically attempt to control their internal world (e.g., their thoughts and feelings) by controlling their external world (e.g., If I don’t leave the basement, I won’t have the unwanted, uncontrollable, distracting, and painful thoughts and feelings about being struck by a meteorite; If I don’t get on the plane, I won’t have the unwanted, uncontrollable, distracting, and painful thoughts and feelings about being in a plane crash).
Unfortunately, this strategy not only takes up tons of time, energy, and dramatically shrinks our lives, it also doesn’t work well. No matter how much control we try to impose on the external world, we continue to notice the uncontrollability of our internal world.
When we notice the ongoing uncontrollability of our internal world, we become even more distracted and anxious. So, we understandably try to regain control of our internal world, imposing more and more controls. This might momentarily help. But then the unwanted internal experiences come back. And so the cycle of loss of internal control, imposing control, next loss of internal control, etc., continues (and often grows).
In ERP treatment, we change how we relate to our internal world.
Instead of trying to control our internal world, we honestly recognize that our internal world is not fully under our control. We admit we can’t stop the thoughts. We admit the thoughts really are scary and make us feel anxious. We admit these scary possibilities could happen.
And we admit that even if the scary possibilities don’t happen, being stuck with unwanted, uncontrollable, distracting, and painful internal experiences really does distract, really does hurt, and really does keep us from being present in our lives as we want to.
It’s scary to admit to ourselves that our internal world is out of control. Imagine trying to explain that to someone who doesn’t know anything about OCD?
Random Person: “Hey bud, how are you doing?”
Those of us with OCD: “Oh, it’s not going so great. My internal world is out of control right now.”
Who of us with OCD would want to tell that to someone? And who of us with OCD want to experience the reality of our internal world being out of control. It’s a terrifying experience – one that research shows everyone goes through but those of us with OCD are especially aware of and sensitive to.
What we learn in ERP, what we see for ourselves in ERP, is that even though we don’t have direct control over our unwanted, distracting, and painful internal experiences, we can handle those experiences, we can meaningfully engage in our lives even when we’re having these experiences, and, over time, these experiences will become less and less common, less and less intense. This reduction in unwanted, uncontrollable, distracting, and painful internal experiences frees us up to more fully engage and enjoy our lives.
References:
Grayson, J. (2014). Freedom from obsessive compulsive disorder: A personalized recovery program for living with uncertainty. Penguin.