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What Are Unacceptable Thoughts?

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What Are Unacceptable Thoughts? Emily Anderson, PhD Christen Sistrunk, MA, LPC Naomi Zwecker, PhD Jennifer Sy, PhD Jessica Gerfen, PhD What are “unacceptable thoughts”? Experienced as unwanted and intrusive Often sexual, violent, or blasphemous in nature Trigger anxiety, guilt, and shame Sexual thoughts Thoughts about having sex with or thinking sexually about inappropriate people or things Thoughts to “go ahead” and do something sexually inappropriate Thoughts about sexual orientation Violent or aggressive thoughts Thoughts or mental images of hitting, stabbing, strangling, or mutilating people, animals, or yourself Thoughts or urges to do “antisocial” things Thoughts of becoming a serial killer (or “what if I am a serial killer?”) Blasphemous thoughts Thoughts against God Sexual thoughts or images about religious figures Thoughts about desecrating or disrespecting religious symbols or objects Thoughts that you have sinned, disappointed God, or behaved immorally Rituals You Can See Physical or Behavioral (overt) Rituals - Checking - External prayer - Reassurance seeking from others - Repeating actions to undo intrusive thought Rituals You Cannot See Mental (covert) rituals to neutralize the discomfort caused by unwanted thoughts - Internal praying - Mental checking, reviewing, reassuring - Pushing away/ thought suppression - Undoing intrusive thought with a good thought - Body checking Avoidance behaviors Avoiding anything that triggers obsessions People Photos TV shows, movies, nightly news Books, articles, etc. Religious services How common is this type of OCD? Many fear that this type of OCD is rare, which only reinforces the feeling that it is “weird” 1-3% of the population have OCD (3-9 million) 25-40% (or possibly more) have “unacceptable thoughts” OCD 1.2 million people in the U.S. likely have “unacceptable thoughts” OCD (750,000-3.6 million) Why do we have these thoughts? Everyone has intrusive thoughts OCD attacks the things you love or value the most If it’s really important to you to be a good person… If you really care about someone or something… Finding a thought to be unacceptable gives it more power Why Me?! It’s not just you! Everyone has intrusive thoughts/unacceptable thoughts We can’t control our thoughts! We have an estimated 50,000 – 70,000 thoughts per day Thought content is linked to emotional state, environment (what we see, hear, smell), memories Our brains are hard wired But my thoughts aren’t normal… ”Normal” people don’t think about this kind of stuff! Unwanted intrusive thoughts are common in over 80-90% of the population (Rachman, 1978) The content of OCD thoughts are the same as non-OCD thoughts (Rachman & deSilva, 1978; Morillo et al. 2007) Even clinicians can’t tell the difference! What makes my thoughts so powerful? When OCD isn’t present, people forget they ever had the unwanted thought shortly after it occurs How OCD evaluates the thought: OCD misinterprets the thoughts as “dangerous” OCD attaches more meaning to the thoughts OCD attaches greater feelings /negative emotion to the thought OCD makes us hypervigilant for negative/unacceptable thoughts…which increases their frequency OCD increases feelings of “punishment” associated with unacceptable thoughts “That was a strange thought” vs. “I shouldn’t have allowed myself to think about that!” “That thought was out of the ordinary” vs. “That means deep down I’m a horrible person “ “That thought was kind of dark, lets think about something pleasant” vs. “ I have to make sure I didn’t truly want to harm them…I couldn’t handle it if there is even a chance I would have enjoyed hurting them” What I have learned about intrusive thoughts following treatment Intrusive thoughts are a part of everyone’s life. They are not dangerous and do not hold special meaning. Others understand intrusive thoughts and in many cases have experienced/can relate to them. My thoughts weren’t unusual. Many people had similar intrusive thoughts. Suppressing/trying to control your thoughts isn’t working! It’s time to try another strategy Thought Control Do NOT think about it Thought suppression When you try to suppress (ignore or get rid of) an unwanted thought, it comes back with a vengeance! Thought control is NOT possible No one can control their thoughts, and we don’t need to try! but HOW you think about what you think. Faulty appraisals It’s NOT the content of the obsession that is causing your distress, it’s what you believe about that obsession. Obsessions may persist because exaggerated importance is attached to unwanted intrusive thoughts. Unwanted Mental Intrusion Anxiety Trigger Decreases/ (people, place, Faulty Appraisal/ Avoidance event) Anxiety Negatively Increases Reinforced Neutralizations & Compulsions Faulty appraisals From David A. Clark’s Cognitive-Behavioral Therapy for OCD Overestimated Threat Thought-action fusion (TAF) Inflated responsibility Over-importance of thought Control of thoughts Intolerance of uncertainty Perfectionism Intolerance of anxiety/distress Your worst obsession Are you concerned that by thinking it you may be more likely to act on it [Thought-Action Fusion]? Does the obsession say something important about you and the type of person you are [Importance]? How important is it that you exercise strong CONTROL over the obsession? Challenging faulty appraisals Cognitive therapy Use cognitive restructuring strategies to create alternative, more helpful ways to think about your obsessions Behavioral experiments Use mini-experiments to test the validity of your faulty appraisals Faulty appraisals and reframes Thought-action fusion Likelihood TAF (“If I have the obsession, then that raises the chances of the bad thing happening.”) Moral TAF (“If I have the ‘bad’ thought it makes me an immoral person and it’s the same as acting on the thought.”) Reframe: Thoughts themselves do not directly effect events in the real world. Morality is based on behavior, not thought. Faulty appraisals and reframes Intolerance of Uncertainty: “I have to be absolutely sure about it and I must get rid of all my doubts.” Reframe: We can never be 100% sure about anything. Uncertainty is part of life and I can tolerate doubt. Trying to be 100% certain is what raises my anxiety. Faulty appraisals and reframes Control of thoughts: “I have to control this obsession or it will control me. There will be bad consequences if I can’t control my thoughts.” Reframe: Trying to suppress and control thoughts is not possible and actually gives the thoughts more importance and associated anxiety. No one can control their thoughts. Faulty appraisals and reframes Over-importance of thoughts: “These obsessions must be important and say something bad about me as a person.” Reframe: Dwelling on thoughts raises their perceived importance. This obsession catches my attention because it is so foreign to my actual beliefs and values. ERP for Unacceptable Thoughts Review of OCD Obsessions Intrusive, repetitive thoughts or images Unwanted, distressing Compulsions Usually performed in response to an obsession Aimed at preventing harm or reducing distress Not necessarily connected in a realistic way What is ERP? Components of Exposure and Response Prevention (ERP) Exposure to stimuli that produce obsessions and fear (face fears) Prevention of rituals to allow for extinction (reduction) of fear How does it work? Promotes extinction Negative reinforcement of escape/ avoidance from feared stimulus (trigger) no longer occurs Modifies mistaken thought processes (e.g., “my anxiety will persist forever”, “Something bad will happen if I do not ritualize”) Within session habituation 10 Anxiety 5 Level 0 Between session habituation 10 Anxiety Session1 Level 5 Session 3 Session 5 0 Hierarchy development Based on obsessions and compulsions, generate list of exposures Physical stimuli and situations that provoke anxiety Thoughts/images that provoke anxiety Must include person’s worst fears Assign a SUDS rating to each exposure Rank order from least anxiety-producing to most anxiety-producing In vivo exposures Generally begin with item that creates moderate level of anxiety Keep attention focused on feared situation Focus on thoughts, feelings, physical sensations, expected consequences Avoid reassurance, relaxation, distraction, etc. Continue until there is evidence of habituation 50% reduction in discomfort from peak levels Imaginal exposures Directly confront distressing thoughts, images or impulses (e.g., images of stabbing a loved one) Used to augment situation exposure; visualize the feared outcomes (e.g., use the knife and then imagine stabbing someone) Visualize confronting a feared stimulus to get oneself ready for in vivo exposure Goals of ERP Goal is not to get rid of all bad thoughts Goal is to accept thoughts, pay less attention to them Stop efforts to fix thoughts/make up for them Externalize thoughts, correct interpretations Let’s Brainstorm! Treating unacceptable thoughts Engage in behaviors that trigger bad thoughts (e.g., being around family and knives) Look at pictures that trigger Watch movies or TV shows that trigger Go to places that trigger Write words that trigger Write sentences of bad thoughts repeatedly Treating unacceptable thoughts Imaginal script Script includes what you are doing, thinking, feeling, what others are doing, the bad consequences, how you react to them Taped or written Look out for rituals/avoidance Closer to worst fears=better exposure .
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