As a clinician who actively treats clients with OCD and provides regular supervision and consultation to other professionals, I regularly hear clients as well as therapists using the term “pure O” to describe a variation of OCD that involves experiencing obsessional thoughts without engaging in any rituals.
I am a big believer in psycho-education, and I spend a good deal of time helping my clients and supervisees to see that compulsions are not only limited to physical actions like checking and washing hands. There is actually a variety of internal, thought-centered rituals that OCD can cause one to complete – things like repeating a certain phrase in one’s head, rehearsing a conversation several times, arguing with one’s unwanted thoughts, reviewing past and potential future events over and over again, etc. There are many ways that people can compulsively ruminate in response to intrusive thoughts and just because these rituals may not involve an active, physical component (such as washing hands, erasing and rewriting, or engaging in a reassurance conversation), it doesn’t mean that the rumination is any less ritualistic or compulsive. It is also important to note that mental rituals can be just as time-consuming and disruptive as physical rituals.
The question that many people with OCD and many people learning the ERP treatment model find themselves asking is “How do I change or stop my thinking rituals?” The answer goes back to the same principles that are used in ERP around physical rituals. To challenge thought-based rituals, you label the OCD thought or image that makes you want to engage in the mental ritual (My OCD just made me see an image of my friends getting into a car crash and now I think it’s going to happen and it will have been my fault) and, instead of doing the mental ritual (I want to say my prayer over and over again until it’s perfect so I can know I’ve done all I can to prevent the crash), engage in conscious exposure to the thought/image/scenario you have been trying to remove (I’m going to let the OCD thought and image stay in my head for as long as it wants to instead of trying to control my thoughts in some way). You can do this by setting yourself a time limit for the exposure (I’m going to experience the image on purpose for a full minute, and I’m not going to do my prayer or try to disprove the thought or argue with it, etc.). You can then add a purposeful distraction after the “exposure time” is done (I’m now going to go for a walk and direct my attention to the colors of the leaves and the feeling of the Fall temperature on my skin). If these steps seem too big, you can also alter your mental ritual (‘I’m going to say the prayer a little bit wrong’ or ‘I’m only going to spend 10 minutes, instead of 20, proving that the OCD thought doesn’t make sense’). If it’s a very strong, habitual mental ritual that seems to happen automatically, you can negate the mental ritual every time you do it (every time I catch myself automatically saying the prayer, I’m going to say to myself “I didn’t really mean it’ or every time I say the word “sorry” in my head, I’m going to say to myself “I’m not sorry.”) It is important to recall that the purpose of ERP is NOT to have better control over our thoughts or get rid of our anxiety. The goal is to learn to live with our unwanted thoughts and tolerate our anxiety, to better anticipate our mental experiences and to challenge the OCD beliefs via exposure—because this allows the individual to disconfirm the OCD expectations.
Using ERP to resist mental rituals seems complicated at first but with practice it can be just as easy as ERP with physical rituals. It is also extremely helpful to incorporate elements of ACT into your treatment, since this can help you to better understand the nature of thoughts and develop a better relationship with your brain. With ACT you work to accept that you can’t control your thoughts and instead direct your attention towards value-driven goals that are a better use of your time. Most people find that their mental rituals are not working to get rid of the problem anyway, so it becomes an easy choice to direct one’s attention towards values-driven activities instead of ruminating. Feel free to check out our site for more information on ERP and ACT treatment.