For the 2016 Annual OCD Conference

1. CBT FOR OCD CHARACTERIZED
PRIMARILY BY INTRUSIVE
THOUGHTS, USING ERP AND ACT
APPROACHES
Renae M. Reinardy, Psy.D.
Kathleen M. Rupertus, Psy.D.
Patricia M. Perrin, Ph.D.

2. OVERVIEW OF OCD AND THEORY OF
EXPOSURE AND RESPONSE
PREVENTION
Dr. Renae Reinardy

3. What are Obsessions and Compulsions?
Obsessions
• Repetitive
• Persistent
• Thoughts, images, urges
• Not pleasurable
• Intrusive
• Unwanted
• Cause distress or anxiety
Compulsions
 Rituals
 Repetitive behaviors
 Mental acts
 Feels driven to perform
 Neutralize
 “Fix”
 Avoid
 Not pleasurable

4.  OCD goes for shock value
 Misconception: “Because I thought it, it must be true”
 Thrives off of uncertainty: “How do I really know if…”
 Common themes: Violent, sexual, religious, and/or moral
What Are Intrusive Thoughts?

5. Violent Obsessions
Manifestations
Harm to…
Harm by…
Obsessions Compulsions
Self/ suicide
Family members
Strangers
Infant/children
Vulnerable
Animals/pets
Loss of control
Sharp objects
Car
Someday I might
I will
I want to
I have
Impulses
Images
Avoidance
Checking
Mental review
Fit it thoughts
Neutralizing
behaviors
Reassurance seeking

6. Sexual Obsessions
Manifestations Obsessions Compulsions
Strangers
Family members
Infants/children
Animals/pets
Sexual orientation
Loss of control
Staring
Rape
Sexual abuse
Exposing
Comments
Uncomfortable
Someday I might
I will
I want to
I have
Impulses
Images
Avoidance
Checking
Mental Review
Testing
Fit it thoughts
Neutralizing
behaviors
Reassurance seeking

7. Religious Obsessions
Manifestation Obsessions Compulsions
Making God angry
Salvation
Blasphemy
Sexual
Serving God
Acting
inappropriately
Decision making
Ultimate sin
Sinful behavior
Hell
Devil
If this then that
Would I rather
That was a sign
God will punish me
I am sinful because
Blasphemous
phrases
Impulses
Images
Avoidance
Repeating scripture
Praying
Fit it thoughts
Neutralizing
behaviors
Mental review
Reassurance seeking
Excessive
confessions
Cleansing rituals
Self-

8. Moral/Antisocial Obsessions
Manifestations Obsessions Compulsions
Arson
Theft
Substance abuse
Property damage
“Bad person”
Racist
Rude
Swearing
Offending
Someday I might
I will
I want to
I have
Impulses
Images
Avoidance
Checking
Fit it thoughts
Mental review
Neutralizing
behaviors
Reassurance seeking

9. • Thought-action fusion
• If I think it, I will do it
• Too much power to thoughts
• Catastrophic thinking
• Fear of loss of control and “snapping”
• Probability overestimation
• Intolerance of uncertainty
• Possibility = Probability
• Hyper-responsibility
• I’d rather be safe than sorry
• Perfectionism
Cognitive Errors of Those with
Primarily Obsessional OCD

10. • Guilty until proven innocent
• Selective attention to “facts”
• I admired guy on front of magazine, I must be gay
• Doubting even having OCD
• Misinterpretation of bodily sensations
• I think it moved
• My body tensed up
• I might have smiled during that thought
More Cognitive Errors

11. CBT Model of ERP
Obsessions
• Trigger (Situation, thought)
• Negative Appraisal (Meaning)
• Anxiety/Discomfort
• Urge to Neutralize (Ritualize)
• Engage in Compulsion
• Temporary Relief
• Strengthening of Obsessions
and Compulsions
ERP
• Trigger
• Negative Appraisal
• Anxiety/Discomfort
• Urge to Neutralize
• Exposure/Response Prevent.
• Habituation of Anxiety/ Lasting
Relief
• Weakening of Association
Between Obsessions and
Compulsions

12. Fear Thermometer
SUDS Rating
Build a hierarchy
10 Freak out anxiety
9 Extreme anxiety
8 Strong anxiety
7 Pretty strong anxiety
6 Kind of strong anxiety
5 Moderate anxiety
4 Somewhat anxious
3 A little bit of anxiety
2 Tiny bit of anxiety
1 Calm

13. • Harm obsessions
Build an ERP Hierarchy
SUDS
09/2016
SUDS
07/2016
Exercise
2 WST- Someday I will step on s/o toe
4 WST- Sometimes people hurt others
6 WST- Someday I will do something I
regret
6-7 WST- I might cause slight harm to
someone I care about
7 Hold a butter knife around others
8 WST- Trigger words (kill, stab)

14. Habituation Happens
10
Emotion
5
1
Time

15. Overview of
Acceptance and Commitment
Therapy
Dr. Kathleen Rupertus

16.  Mindfulness-based behavior therapy with roots in relational frame
theory (RFT)
 Accept- willingness to allow the experience to be just as it is
 Choose your direction based on personal values
 Take Action in ways which reflect your values to make your
life meaningful.
 “Life need not be determined by how much or how little anxiety
you have.”
Acceptance & Commitment Therapy

17. ACT Hexaflex
Psychological
Flexibility:
Be present,
open up, do
what matters
CONTACT WITH PRESENT MOMENT
Be here now
VALUES
Know What Matters
COMMITTED ACTION
Do what it takes
OBSERVING SELF
(Self-as-Context)
Pure Awareness
ACCEPTANCE
Open up
DEFUSION
Watch your thinking
Source: Harris, R., Act Made Simple

18. Mindfulness and Acceptance
 acceptance
 defusion
 contact with the present moment
 self as context
Commitment and Behavior Change
 committed action
 values
 contact with the present moment
 self as context
2 Functional Categories:

19.  alternative to experiential avoidance
 actively and intentionally embracing the experience
fully and without defense
 willingness to accept the experience just as it is...
 “Are you willing to experience the anxiety if it
means
you get to have the good stuff?”
Acceptance

20.  mindfulness
 to reduce the literal quality of the thought
 weakens the tendency to treat the thought as what it
refers to
 Techniques:
 repeatedly write or say out loud the thought/word
 “I’m having the thought/feeling/sensation…”
 observe the experience- “There’s thinking/feeling…”
 thank your mind for the thought
 What do “I” think about that?
Defusion

21.  ongoing non-judgmental contact with the experience
 it is impossible to not judge
 the goal is to get better at noticing judgments in order to
reduce the literal quality of the thought
 weakens the tendency to treat the thought as what it refers
to
Contact with the Present Moment

22.  self as a perspective, not an absolute
Self as Context

23.  What would you be doing with your life if OCD was
not in your way?
 Make decisions based on what deeply matters to you
What truly matters in my life, beyond this
moment/feeling/experience?
How satisfied am I in those areas?
In what ways are my struggles with anxiety interfering with doing
what matters to me in my life?
In what ways are my struggles with anxiety impacting my
satisfaction in those areas?
Values

24.  … are on-going commitments with no end-point
 … serve as a compass
 Emotional outcomes are not values
 You follow values despite the emotional outcome
Values

25.  “It is about doing, and doing in the direction of what
you value and care about.” (Forsyth & Eifert, 2007)
 Action that is linked to a person’s chosen values
 Results in attainment of goals, behavior change, and
behavioral and psychological flexibility
Committed Action

26.  Decrease experiential avoidance
 Increase flexible behavior
 Defusion
 ACT: “There’s thinking… That’s an interesting thought.”
 ERP: “That’s my OCD… what’s my best guess?”
Similarities: ACT and ERP

27.  ACT: Engage because of who you want to be (values)
 ERP: Engage because of what you want to get rid of (anxiety)
 ACT- Context of the thought is emphasized
 ERP- Content of the thought is emphasized
 ACT- Measures outcome based on moving in a valued direction
 ERP- Measures outcome based on SUDs reduction
Differences: ACT and ERP

28.  ACT: Greater reliance on metaphor and experiential exercises
 ERP: Greater reliance on instructive psychoeducation
 ACT
 Focus on willingness to experience discomfort vs habituation
 Greater reliance on defusion (detach from meaning of thoughts)
Differences: ACT and ERP

29. TREATMENT OF OCD USING
ERP and ACT
Dr. Patricia Perrin

30. • Identify and challenge cognitive errors/traps (probability
overestimating, intolerance of uncertainty, giving too much
importance to thoughts, hyper-responsibility, etc.)
• In vivo and imaginal exposures
• “Exposure to uncertainty”- to fearful thoughts, living with
uncertainty that feared outcome may occur
• Exposure to trigger words embedded with neutral words
• Using exposure cues to address unpredictability and
uncontrollability of intrusive thoughts
• Use of an ACT metaphor to demonstrate acceptance, defusion,
living a values based life, etc.
Overview Of ERP and ACT Treatment
Approaches for Intrusive Thoughts

31. Anxiety
- Anxiety goes down
- Obsession comes back
- Anxiety goes up higher
- Checking again
- Obsession comes back
- Sense of loss of control
- Anxiety goes up even higher
Consequences of
Checking
(Freeston, 1998)
CHECK!!!
CHECK
CHECK!
CHECK!!
CHECK!!!!

32. Anxiety
-First time: anxiety goes up, stabilizes,
comes down by itself
- With practice, goes up less and
comes down faster
- When really good, trigger almost
unnoticeable
Exposure and
Response
Prevention (i.e., no
checking)
(Freeston, 1998)

33. Harming Obsessions:
Leave knives out/ Talk to spouse holding knife
Drive by schoolyard with children playing
Bathing / playing with baby alone
Driving down road with potholes and not going back to check
Sexual Obsessions:
Seeing attractive women/men in gym locker rm.
Looking at attractive women/men in magazines, catalogues, on
TV, in movies
Talking to attractive women/men at work/school
Thinking about genitals of people in store, or at luncheon
ERP: In Vivo Exposures

34. Scrupulous (Religious or Moral) Obsessions:
• Praying an “imperfect” prayer, or a different prayer
• Reading Bible w/o being sure about meaning
• Going to communion while uncertain as to whether one has
sinned
and should go to confession
• Eating a food you are not “perfectly sure” is Kosher
• Touching paper that has been at school where students use bad
words, fearing that it will make you use bad words
• Turning in test although you glanced at a student’s paper and
fear that you cheated
ERP: In Vivo Exposures

35. • Imagining feared event:
• Accident in which loved one injured
• You standing over someone you stabbed with knife in your
hand, and bloody scene
• You saying blasphemous things
• Imagining feared scenario with possible negative
consequences for you (imaginal exposure script)
ERP: Imaginal Exposures

36. We all live with uncertainty:
House could burn, flood while away – we still go out
Car accidents happen – we still drive
Unpredictable weather - we still go out
OCD causes intolerance of uncertainty due to
1) giving too much importance to unchosen thought
2) misperception of responsibility/control
3) having intrusive thoughts of “the most inappropriate or awful
thing you could do” (Baer, L., Imp of the Mind)
Goal of treatment: Increase tolerance of uncertainty
Exposure to Uncertainty - Rationale

37. Trigger: 1) Touching door knob
2) Intrusive thought: I might stab a loved one.
Ritual considered: 1) Wash hands
2) Reassure self that you would do no harm
Response prevention:
1) Don’t wash hands
2) Don’t reassure self.
Do exposure to uncertainty/don’t reassure:
1) Maybe I will get sick, maybe I won’t. No way to be sure.
2) Maybe I will harm loved one, maybe I won’t. Can’t be
certain.
Exposure to Uncertainty – Similarity to
Exposure to Contamination Triggers

38. • Identify the anxiety inducing thought, e.g., “I could drown my
new baby.”(common in postpartum OCD)
• Establish that this is an undesirable thought, (ego-alien vs. ego-
identified) that creates anxiety.
• Do Exposure to Uncertainty: Say repeatedly (for example):
• Maybe I do want to drown my new baby.
• Maybe I don’t.
• There’s no way to be sure.
Exposure to Uncertainty
(My Secret Weapon) - Format

39. • Identify anxiety/discomfort SUDS (subjective units of distress
scale) level (0 -10) caused by saying or thinking these thoughts (i.e.,
by exposure to the intrusive thoughts of uncertainty).
• Repeat statements to yourself until you notice your level drop to
half of highest.
• Be careful NOT to reassure yourself.
• Think of Psychological Aikido – Using force of opponent (thought)
against itself (Don’t engage thought. Let it go. Live with
uncertainty.)
Exposure to Uncertainty Techniques

40. • Harming Obsessions: Maybe I do want to stab him, may I don’t.
There’s no way to be sure. Maybe I do want to molest
children, maybe I don’t. I can’t be certain.
• Sexual: Maybe I’m gay, maybe I’m not. I can’t really tell. (SO-OCD)
Maybe I do want to have sex with my (family member),
maybe I don’t. I really can’t be sure.
Because I find that woman attractive, maybe that means I
want to leave my wife, maybe it doesn’t, I really can’t be
sure. (Relationship OCD)
• Religious: Maybe I’m not a good Christian (Jew, Muslim, etc.).
Maybe I am. No way to be sure.
Maybe I want to curse God, maybe I don’t. No way to know.
Exposure to Uncertainty - Techniques

41. • For trigger word “kill”, create list of rhyming or similar words,
repeating list saying each word 1x, then 2x, then 3x. Rate anxiety
after 2-3 rounds of reading each list, until anxiety to trigger word
drops to half.
Bill Bill Bill Bill Bill Bill
Sill Sill Sill Sill Sill Sill
Kill Kill Kill Kill Kill Kill
Mill Mill Mill Mill Mill Mill
Fill Fill Fill Fill Fill Fill
Exposure to Trigger Word “Kill”
Embedded with Neutral Words

42. DEVIL DAMN SUICIDE (Not Suicidal)
Revel Sam Pesticide
Disheveled Lamb Fireside
Devil Damn Suicide
Bevel Ham Coincide
Level Tram Countryside
Exposure to Trigger Words ‘Devil,’ ‘Damn’
and ‘Suicide’ Embedded with Neutral Words

43. • To address unpredictability/uncontrollability of intrusive
thought or image, which contributes to shock effect and
anxiety/distress:
• Choose cue word and think of thought/ image when you hear
someone say it (e.g., weekend, today, car, store, start, etc.)
• Choose cue time (e.g., every hour on the hour)
• Set alarm on phone to cue doing an exposure
• Choose cue activity (entering a room, hanging up the phone,
stopping at red light)
• Put trigger word in drawer you open frequently
ERP: Imaginal Exposure to Address
Unpredictability/ Uncontrollability of Intrusive
Thoughts

44. • When cued by word, time, alarm, activity, opening drawer, do one
or more of the following:
• Exposure to uncertainty
• Bring intrusive image to mind
• Exposure to word embedded in list of neutral words
• Listen to imaginal exposure script
ERP: Imaginal Exposure to Address
Unpredictability/Uncontrollability
of Intrusive Thoughts

45. ACT Hexaflex
Psychological
Flexibility:
Be present,
open up, do
what matters
CONTACT WITH PRESENT MOMENT
Be here now
VALUES
Know What Matters
COMMITTED ACTION
Do what it takes
OBSERVING SELF
(Self-as-Context)
Pure Awareness
ACCEPTANCE
Open up
DEFUSION
Watch your thinking
Source: Harris, R., Act Made Simple

46. • Bus – Your life
• Passengers – Some memories, thoughts, and emotions
which you like. Some loud and unruly passengers, e.g.,
conditioned emotions, fearful thoughts, sensations, and
urges that you experience in life, which you don’t like.
• Driver – Whatever directs your life - Preferably you.
• Sign on front of bus – Destination of bus: 1) “Struggle with
OCD or Fearful Thoughts,” or 2) “Values Based Life” or
“Value Mountain”
ACT Metaphor: Passengers on the Bus or
Driving Your Life Bus
Sources: Hayes, S.C. Get Out of Your Mind & Into Your Life; Forsyth, J.P., and Eifert, G.H.
The Mindfulness and Acceptance Workbook For Anxiety

47. • When struggling to eliminate the source of anxiety, you
spend a lot of time trying to get unruly passengers off the
bus. You stop the bus, i.e., put values driven life on hold.
• You turn around to try to quiet the loud, frightening
passengers who say “don’t go there, it’s dangerous”. You
do compulsions, (seek reassurance, avoid triggers for
uncertainty and anxiety, do thought suppression). You
miss your turn or let go of the steering wheel, and you
lose your direction. You have lost control of the bus.
• Result – you struggle because you cannot accept what is,
anxious feelings are driving the bus, and result is you
suffer.
ACT Metaphor: Passengers on the Bus and
the Nature of Struggle

48. • When you accept that on the road to Value Mountain, you might
feel anxious, or having troubling thoughts, you keep driving in your
chosen direction.
• You keep your eyes on the road to your destination, you control
the steering wheel. You observe thoughts of fear or uncertainty,
with detachment. Do not spend time or attention on them.
Choose how to direct attention, in the present.
• Result – Live values based life, w/o struggle, suffering.
ACT Metaphor: Passengers on the Bus
and the Nature of Acceptance

49. • Acceptance - Instead of avoidance, and doing
compulsions, you develop a willingness to have the
thoughts and feelings with you
• Defusion – you notice thoughts and feelings with
detachment, as if watching on movie screen
• Awareness – you observe thoughts and feelings, without
judgment, or struggling with them, or having to make
them go away
ACT Metaphor: Passengers on the Bus
and the 6 Core Process of ACT

50. • Contact with Present – You let go of worrying about
what intrusive thoughts you had in past and how the
anxiety they cause might affect future, and connect
with the present
• Values – you change sign on front of bus from
“Struggle with OCD or Fearful Thoughts” to “Values
Based Life,” or “Value Mountain”
• Committed Action – you become the driver; you drive
bus; you choose the direction of your life, with our
without anxiety
ACT Metaphor: Passengers on the Bus and
the 6 Core Process of ACT

51. •Trigger Situation
•Initial Intrusive Fearful Thought / Image
•Emotional Reaction; Physical Symptoms
•Additional Fearful Thoughts; Doubting Thoughts
•Urges to Ritualize, Without Follow-Through
•What This Would Say About the Person
•Core Fears – Worst Case Scenarios
Scripts for Imaginal Exposure

52. Renae M. Reinardy, Psy.D.
Lakeside Center for Behavioral Change
Fargo, North Dakota
info@lakesidecenter.org
www.lakesidecenter.org
Contact Information

53. Kathleen M. Rupertus, Psy.D.
The Anxiety and OCD Treatment Center
Wilmington, Delaware
DrKathyRupertus@gmail.com
www.OCDdelaware.com
Contact Information

54. Patricia M. Perrin, Ph.D.
OCD and Anxiety Treatment Center of Houston
Bellaire, Texas
patperrin@sbcglobal.net
www.ocdtherapyhouston.com
Contact Information