CBT Cognitive Behavior Therapy

1. CBTCognitive Behavior Therapy ERP Exposure and response prevention

2. How can we apply these tools to obsessions that do not have a clear compulsions attached to them Before we explain this, I must preface that almost all mental obsessions have some kind of compulsion attached to them, but this is usually in the form of mental checking, mentally neutralizing or at least some form of avoidance.

3. OCD in the form of Intrusive thoughts 1) Violent obsessions • Religious obsessions • Neutral obsessions • Certain fears • Obsessions about obsessing

4. Violent obsessions • Most violent obsessions take the form of thought such as: • What if I were to throw my baby out the window? • What if I were to molest my child? • Picture self stabbing someone.

5. 3 Major feared consequences 1)These are terrible, low thoughts. I must stop them. 2) Only terrible people have these thoughts, am I so terrible? 3) How do I know that I will not act on these thoughts.

6. Thinking Rituals • Analyzing and figuring out a way to prove to yourself that the thoughts don’t really mean anything. • Even once you hear that some people obsess over these things you continue to obsess whether or not you really have OCD and is that the real cause of these thoughts or am I like one of those evil serial killers… • Why did my OCD take this form there must be some truth to it

7. Thinking Rituals • Putting yourself in the situation to Prove to yourself that you will not do that act • proving to yourself that you are not that kind of person. • trying to come up with reasons why I had these thoughts. • Going out of your way to be nice to show yourself that you are really good. • Avoiding objects or situations that may trigger these thoughts. • Playing it safe – staying away from people that you may harm, staying away from sharp objects that could be used to act on one of these obsessions…

8. The goal of recovery Learn to live with them • Not to stop the obsession from coming to your mind or even to make them less frequent • (although it’s true that it will become less frequent if you stop caring about them)

9. goals of treatment • Learning how to allow your obsessive thoughts to be there. • Learning how to stop wishing. • Script and loop tape repeating the word or short thought to desensitize.

10. Everyone has violent and all sorts of crazy thoughts passed through their mind from time to time/ • The more inappropriate and frightening the thought is to you the more likely you are to push it away and that the more likely it is to haunt you • Of these thoughts are parts of the מציאות of this world and does not make you a bad person • The more you try to suppress these thoughts the stronger the thoughts will become • The more you avoid situations that trigger your thoughts the worse the problem will become • If you stop trying to suppress that thoughts they will eventually pass naturally through your mind • Your goal is not to be able to completely control your thoughts – no one can do this!

11. how can I be sure that I will not act on them and that they are only OCD • No one can know for sure that he will never commit an act of violence • I would be more concerned about someone with no doubt and no worry much more • As a matter of fact people obsess about the ideas they find craziest, so your obsessions in essence is a proof that you are highly unlikely of ever doing it • The only time to worry is if you hear voices telling you to do so, or if you have committed this type of crime in the past • Remember this is not a proof, that we are not looking for a proof, since it is impossible to prove. • However this is enough to rely on in a logical world

12. Method of exposure • Therapy scripts for imaginal exposure • A hierarchy will be necessary where you begin with easier less offensive scripts and keep intensifying them until you reach total habituation of these thoughts

13. Therapy scripts • A script is the description of how you think including: • All the thoughts that annoy you • All the feared consequences • All the things that will happen if you do not take care of this soon • What having these thoughts means about you

14. Sample script for violent obsessions There is no way for me to truly protect my son from myself I just have to live with the possibility that I could lose control and stab him tonight. If I do lose control I may take the kitchen knife and stab my innocent lovely child while he was sleeping. The poor kid would not be able to defend himself and although he did nothing wrong besides be born to such a horrible father.

15. Right after doing this I would feel so terrible, how could I have done such a horrible thing, I will never feel like a human person again there will not be any purpose in living. • It will not be long until I am caught, it will be the front cover on all the newspapers of how cruel a man can be and it will be my picture at its side. • I guess I will sit in jail for life • Even after all of this I will not be finished because I will come up stairs and they will start to give me the worst punishments around I will not have this world or the one to come • I am having these thoughts because I am really a psychopath who will probably do this.

16. Script tips • Always put the fear in the form of a “maybe” Happening as opposed to definitely happening 1) since that is the form of the fearful thought, try to stay as close as possible to the reality of the thoughts. 2) Your goal in treatment is learning to live with uncertainty.

17. Never put in any words of sympathy or security or anything that may reduce some stress • Although I know that I don’t really think that I will ever actually do anything like this • This is probably just ocd • I really hope that this won’t actually happen – because I wont survive • I hope that this will go away very soon

18. Stop the avoidance • Leave knives around • go into your child’s room when he is sleeping holding a knife • tell someone that you are having these thoughts. • Do not avoid reading the story is that describe people who have done such things

19. Tava obsessions • We will deal with this separately since we have to first learn how to diffrentiatebetween real Taave and OcD • also we can’t quite use the exposures that are mentioned since you can’t expose yourself to shmutz. • We will have a separate week for this

20. Emuna Obsessions • Here too we can’t use the regular exposure as well as the accepting uncertainty since you can’t say “so maybe I am not maamin” even as an option or chance • We will spend a full week on this too

21. Neutral obsession • A thought, Image or sensation that has no negative meaning but you get Stuck on it and begin worrying that it will never leave you • obsessing of how much better life would be without these obsessions. • Avoid certain enjoyable activities since you know that you won’t be able to enjoy them because then obsessions will come bother you • This may be followed by blaming all your life's problems on your obsessions

22. Thinking about your breathing • Thinking about my glasses being comfortable • Focusing on minor aches or sensations • Thinking about hearing ringing or other sounds in the ear

23. Script tips • The reason for the silence is to have the experience of having the word pop into your mind unexpectedly. • Play this script constantly as much as you can • This will also help you settle for less instead of getting maximum enjoyment from life and stop wishing and blaming

24. Goal of scripts in neutral obsessions • Scripts make it impossible to stop thinking about your obsession and you will eventually give up trying. • Record yourself saying the script and pausing with a quiet period of between eight and 30 seconds. • You should engage in as many activities as you can while listening to the script.

25. Obsessing about obsessing • This happens when the initial form of your OCD becomes less important than the fact that you are obsessing • Very often this comes with rituals to try to make the obsessions stop, for example every time you get an obsession you would think which method should I use to stop the obsession

26. Script for obsessing about obsessing • I think that I have a real problem, I cannot stop thinking. At least when they were OCD thoughts I knew how to do exposures and so on. But now my whole head became so frozen that I do not even know what I am thinking about anymore I am just confused, I just have no patience left. Everything I tried does not work and there is no way that I can learn or enjoy life with all this stuff going on in my head. I am hopeless I better give up. I well never get better. I will be a לא יוצלח worse than even the weakest Bochurim.

27. For numerous obsessions that keep changing from one to the other When the obsessions become very many and a jump from one to the next, it will be better to make a simple loop script describing the idea of obsessing. For example, here is the nudge, I recognize his drunk.