Jonathan Grayson, Ph.D.

Grayson: CT Must be Modified To Treat OCD

By Lynn Mollick & Milton Spett 

            Before he said a word at his October 8 workshop for NJ-ACT, Jonathan Grayson lifted his foot, wiped the bottom of his shoe with his hand, and proceeded to lick his hand. He was demonstrating exposure and response prevention (ERP), the critical intervention for treating contamination obsessions and other forms of OCD.

            Current theory assumes that obsessions create anxiety, and compulsions are attempts to reduce that anxiety. ERP asks patients to expose themselves to their obsessions, experience the attendant anxiety, but refrain from performing any compulsion, such as reassurance-seeking, that would reduce their anxiety.

Dr. Grayson asserted that severe OCD can be very effectively treated, but patients must practice “total immersion” in the treatment process. Patients should not just touch what they fear touching and expose themselves to their obsessions -- they must practice ERP over and over, and think about ERP every waking moment. Wait a minute, Dr. Grayson also pointed out that patients can listen to recorded scripts while they sleep.

Scripts for Total Immersion in ERP

            Scripts are one of Dr. Grayson’s major contributions to the art of treating OCD. Scripts are treatment-supportive instructions the therapist records on CDs or tapes during therapy sessions.  Dr. Grayson asks patients to buy headphones and listen to their scripts whenever possible. As he puts it, “OCD never rests. Why should treatment?”

            Scripts are developed with information that emerges during therapy sessions. They may be as brief as a minute or two, or as long as a quarter hour, but they should always elicit intense emotion. 

            Unique scripts should be developed for each patient, and a patient’s scripts will change as treatment progresses. Dr. Grayson recommends that anyone who treats OCD learn to make CDs on their computer. Here are the most common types of scripts:

            1. Exposure. By reminding the patient of the dangers they fear, listening to a script can constitute exposure.

            2. Motivation. Remind patients of what they have lost to OCD and how much more they will lose. Are they willing to live with OCD forever? 

            3. Instruct patients to constantly do ERP. 

            4. Remind patients that they can never achieve complete safety. They must learn to be happy in a world where they could be contaminated, die, or kill someone at any time.

Acceptance of Uncertainty

            Dr. Grayson asserted that cognitive therapy was developed for treating depression, and must be modified when treating OCD. OCD sufferers anticipate negative events, become anxious about these anticipated events, and then perform compulsions to reduce their anxiety. The sufferer’s goal is 100% certainty that the feared event will not occur. But this goal can never be attained. Instead, the key to successful treatment of OCD is to convince these patients to accept uncertainty and anxiety. Dr. Grayson asked if any audience members were 100% certain that they would not kill a loved one that evening (a common OCD obsession). No one could honestly answer “yes.”

            Suppose a patient says "I believe I may have contracted AIDS by shaking hands with a man who looked gay." A typical cognitive intervention might be "Let's look at the evidence for the possibility that you have contracted AIDS." But Grayson argues that you should never try to convince OCD patients that their fears are unwarranted. This type of cognitive intervention may reduce anxiety temporarily, thereby reinforcing the OCD patient’s compulsive reassurance-seeking. But the obsessive fear and compulsive reassurance-seeking will return stronger than ever.

            Instead, you should try to help OCD patients to accept uncertainty and anxiety. Dr. Grayson suggested saying: “If you do get AIDS, our goal will be to help you cope with the remainder of your life in a positive way, which will be really important, since your life might be short, although people with AIDS live longer now. If you don't get AIDS, your current obsessive seeking of reassurance and certainty will cause you to have a long, miserable life in which all of the joys of life will pass you by.” Grayson constantly reminds OCD patients that they are ruining their lives by seeking reassurance and certainty.

Motivating Patients to do ERP

            Dr. Grayson begins treatment by asking patients if they are willing to work on learning to live in an uncertain world. If patients say they want to stop worrying and be certain that bad things will not occur, the therapy cannot proceed. Dr. Grayson asks patients to compare the harm OCD does to them and their loved ones with the benefits of reassurance seeking. He asks OCD patients to complete forms evaluating “What Have I Lost to OCD,” “How Giving in to OCD Has Hurt My Loved Ones,” and “Cost Benefit Analysis of Accepting vs. Refusing Treatment.” This analysis provides motivation for enduring the rigors of ERP and living in a world where nothing is 100% certain.

            Dr. Grayson constantly reminds patients that their compulsions are ineffective. For example, if they compulsively wash to avoid germs, remind them that germs are everywhere. Everything they touch has germs, and the only way to be completely safe is to wash every item in their house, never go out, and never let anyone in who isn’t completely germ-free. He tries to convince OCD patients that they can never achieve 100% certainty, and it is much more practical to work toward accepting and living with uncertainty.

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