Jonathan Grayson Addresses NJ-ACT on Intolerance of Uncertainty in OCD
Part 1 – General Principles
By Lynn Mollick
Los Angeles psychologist Dr. Jonathan Grayson presented NJ-ACT’s 23rd annual Master Lecture on March 18, 2018. His topic was “Treating Doubt and Intolerance of Uncertainty in OCD.” 101 mental health professionals attended. This is part 1 of our summary of his presentation.
Certainty is Unachievable
Dr. Grayson considers Exposure and Response Prevention (ERP) to be the essential treatment for OCD. But patients are usually reluctant to perform ERP exercises unless they are certain that the feared outcome will not occur. Thus, the first focus of OCD treatment is helping patients learn to live with uncertainty and to accept the goal of learning to live with uncertainty.
Dr. Grayson motivates patients to accept uncertainty by telling them that certainty is unachievable. He gives them concrete examples of how their compulsions will never make them completely “safe” from what they fear.
1. Do you know that a loved one is alive? Unless that loved person is in the room with you, you cannot be certain.
2. No amount of handwashing can ever prevent contamination. As soon as you turn off the faucet, use a towel, or touch the door knob after washing, you immediately re-contaminate your hands. In addition, no one can ever clean enough to make their environment 100% germ-free. Avoiding risk is not a possibility.
Since handwashing patients are already contaminated, Dr. Grayson encourages them to do exposure by telling them to be consistent. “You’re already contaminated. Give up trying to be contaminant-free. Touch dirty things and contaminate yourself and your entire environment.”
But why should patients take seemingly enormous risks to perform ERP? You can build motivation by asking them what they’ve lost to OCD or how their OCD has hurt their loved ones. Forms for this assessment available at freedomfromocd.com.
Dealing with Co-morbidity
Carefully assess both problems. Do they share intolerance of uncertainty as a symptom? If so, treat both simultaneously. If not, evaluate which makes sense to treat first.
When comorbidity exists, it is often helpful to make a flow chart illustrating the causal relationships among all of the patient’s symptoms.
Strategic Pressure – Treatment of Last Resort
Strategic Pressure is appropriate when patients have “hit rock bottom” and OCD becomes life threatening. It can be used with children and young adults who live with their parents, do not pay rent, and have refused all treatment for OCD. In addition, parents must believe that Strategic Pressure is the only alternative to disability.
Parents present the patient with forced choices: practice ERP and take a tiny step toward better functioning or accept a slightly more distressing, parent-implemented consequence that is also an exposure.
Initially, parents meet with the therapist alone. The therapist instructs the parents to go home and tell the patient that they are trying a new treatment called Strategic Pressure. If the patient asks what Strategic Pressure is, the parents should say “I don’t know. The therapist hasn’t told us.” If the patient threatens not to participate, the parents should say “I’m sorry you feel that way.”
Parents learn to communicate with patients without arguments and negotiations. Patients learn that noncompliance has consequences. But the parents must do exactly what the therapist advises without improvising.
Every week parents present the child with a written contract that describes precisely what exposure exercises are being requested of the patient and precisely what the consequence of failure to do the exercises will be. Both alternatives involve exposure.
The first contract should require something that is not very difficult for the patient with a consequence that is not especially unpleasant. The intensity of the exposures increases very gradually. If the child does not like a contract, he/she must suggest an alternative. This motivates the child to attend sessions with their parents. Eventually, patients almost always accept treatment on their own. Treatment is extremely slow.
Clinical vignette
Dr. Grayson described an adolescent patient whose OCD was so severe she spent 24 hours a day in an 8 by 10 foot space in one corner of her house, and had declared much of her house off limits to her family. Treatment began by requiring her to step out of her safe zone for a short period or suffer the consequence of a family member moving one of her stuffed animals. (The patient had an obsessive fear of anyone touching her stuffed animals.)
Following this forced choice procedure, over the next two years the patient progressed to participating in individual treatment, attending school, taking medication, and tolerating her family’s free movement around the house.