For the 2016 Annual OCD Conference

1. MINDWASHING:
MASTERINGTHE UNIQUE
CHALLENGES OF MENTAL
RITUALS
Jon Hershfield, MFT
MonnicaWilliams, Ph.D.
Elspeth Bell, Ph.D.
Jeff Bell
The 23nd Annual IOCDF Conference
Chicago, IL July 29th 2016

2. Why this talk?
• OCD sufferers often unaware of role of mental
rituals or unable to articulate experience of them
• Clinicians often misdiagnose OCD as GAD or
other disorders
• Both need a language for assessing and treating
OCD in the absence of overt observable rituals

3. OCD BASICS
• Obsessions – unwanted intrusive thoughts that
are associated with discomfort, often repetitive,
typically ego dystonic
• Compulsions – physical OR mental behaviors
engaged in for the purpose of seeking certainty
and relieving discomfort associated with
obsessions

4. But the DSM says…
• Presence of obsessions OR compulsions.
• But really people with OCD have obsessions
AND compulsions (Williams et al., 2011;
Leonard & Riemann, 2012).
• You just have to be able to identify the
compulsions!

5. “PURE O” OCD
• Misnomer used to identify sufferers whose
compulsions are primarily mental or covert
• Term “pure obsessional” showed up in early 90’s, then
replaced with “primarily obsessional”
• Is not a clinical reality or separate diagnosis from OCD
• Label used by sufferers for fostering sense of
community

6. Rates of Covert Compulsions
by Primary ObsessionType

7. OBSESSIONS
• All obsessions involve mental rituals, though
some are more commonly associated with
“pure o” or invisible compulsions

8. OBSESSIONS
• Contamination obsessions may involve
physically washing, cleaning, and avoiding,
but also involve significant mental rituals
• Responsibility obsessions may involve
repeating and checking, but also involve
significant mental rituals

9. COMMONLY ASSOCIATEDWITH
SIGNIFICANT MENTAL RITUALS
• Harm OCD – obsessive thoughts of
aggression, fear of acting out violence
impulsively or self-inflicting harm

10. COMMONLY ASSOCIATEDWITH
SIGNIFICANT MENTAL RITUALS
• Sexual Orientation OCD (a.k.a. HOCD) – fear
of “turning into” or being in denial of other-
orientation identity

11. COMMONLY ASSOCIATEDWITH
SIGNIFICANT MENTAL RITUALS
• Pedophile OCD (a.k.a. POCD) – fear of being
sexually attracted to children or impulsively
acting out sexually with children

12. COMMONLY ASSOCIATEDWITH
SIGNIFICANT MENTAL RITUALS
• RelationshipOCD (a.k.a. ROCD) – fear of
inadequacy or dysfunction in romantic
relationship

13. COMMONLY ASSOCIATEDWITH
SIGNIFICANT MENTAL RITUALS
• Scrupulosity – religious or moral rigidity, fear
of being disconnected from faith,
blaspheming, or being morally inadequate

14. COMMONLY ASSOCIATEDWITH
SIGNIFICANT MENTAL RITUALS
• Hyper-awareness obsessions – discomfort
associated with awareness of involuntary
processes (i.e. blinking, breathing,
swallowing, or thought process)

15. MENTAL RITUALS
• Thoughts as contaminants of the mind
• Some people wash their hands, some people
wash their minds

16. MENTAL RITUALS
• Covert compulsions
• Often un-noticed by others
• Often overlooked by treatment providers
• Sufferer may be unaware or believe mental
behavior to be non-compulsive

17. MENTAL REVIEW
• Mental review is occurring when a person is examining a
past experience repeatedly for the purpose of letting it go.
This is sometimes referred to as “rewinding the tape”
because it is the mental equivalent of studying a scene
over and over. Since the sufferer believes that reviewing
the event (interaction, conversation, statement, etc) will
result in resolving it and subsequently reducing
uncomfortable thoughts and feelings, it is a compulsion.

18. MENTAL REVIEW
• Often confused with “just working it out” or
honest attempt to gain insight into or
understand meaning of obsession
• Interchangeable terms - retracing, replaying,
rewinding, ruminating

19. MENTAL CHECKING
• “Digging up” a thought for the purpose of engaging in
mental review. This also occurs when a sufferer
becomes aware of an obsession being absent. They
then mentally “check” to see if the thought still
bothers them and compulsively test it to see if it is
truly resolved. This is essentially bringing on an
obsession to prove it has gone away.

20. MENTAL CHECKING
• Can also be applied to feelings and bodily
sensations, such as in checking one’s groinal
response to a sexual obsession. This includes
mentally investigating the potential source of
a thought or feeling to determine why it
occurred.

21. SCENARIO BENDING
• Hypothesizing, theorizing, exploration of whatWOULD happen
• This mental ritual combines review and checking by first
replaying an event that did take place, and then adding a
hypothetical element of the event that could have but did not
take place. Someone engaging in this compulsion would then
proceed to analyze how they would have behaved if the feared
scenario did take place. The ritual is aimed at determining how
appropriately one would respond in a feared hypothetical
scenario in the hopes that they will have certainty of their moral
constitution.

22. REVERSE RUMINATING
• Mental rehearsal
• While mental review often involves replaying the past, “reverse
ruminating” involves playing back invented ideas of the future in an
attempt to check for likelihood of catastrophe. Unlike scenario
bending, which starts with a real event, reverse ruminating takes
place entirely in the future, at an upcoming performance, encounter,
interview or some other future event that could go terribly wrong.
• often confused with simply preparing, but it is better described as
compulsively going over and over something that has yet to happen
in an attempt to relieve discomfort about what could happen.

23. THOUGHT NEUTRALIZATION
• This is a mental behavior centered around silently
saying words or attending to thoughts that are the
opposite of the unwanted ocd thoughts. The belief is
that a “good” thought will neutralize a “bad” one and
preempt unwanted consequences.
• Can include intentional focus on opposite feelings to
neutralize intruding ones.

24. SELF-REASSURANCE
• Many OCD sufferers ask people close to them to help them
attain a sense of certainty about an obsession. They may also
do this through compulsive research on the internet or
elsewhere.
• Self-reassurance comes in the form of mentally repeating
reassuring statements to gain a sense of certainty that the
unwanted consequences of a thought will not occur. Often
times this is a ritualized version of positive affirmations.
• May involve mental review of previously acquired reassurance.

25. SELF-REASSURANCE
• Contingency planning – reviewing fantasy scenarios in which the
feared consequences are coped with or neutralized (e.g. repeatedly
telling yourself you’ll escape to Argentina to avoid prosecution for a
feared crime)
• Suicide fantasies – function as a wishing ritual, imagining a space in
which the thought ceases to be present or as a contingency plan (see
above). Must be distinguished from actual ideation or intent.
• Celebrating – Excessively focusing on moments wherein the
unwanted thoughts are absent, self-reassuring that they are really
gone and not coming back.

26. COMPULSIVE
FLOODING/TESTING
• As a behavioral technique, flooding can be an effective form
of short-term exposure with response prevention for an
unwanted thought. It would typically take the shape of
agreeing with and exaggerating the thought until habituated.
• May be distorted into a form of testing reactions to situations
by forcing unwanted thoughts in specific circumstances.
Because it is painful, it demonstrates that the thoughts are
ego dystonic and this functions as a form of self-reassurance
(this is very prevalent in sexual and harm obsessions).

27. COMPULSIVE
FLOODING/TESTING
• Can be associated with “backdoor spikes” in which sufferer
is concerned that they are not as anxious about a thought
as the “should” be.
• Often goes un-noticed by treatment providers but causes
unnecessary suffering with no habituating payoff
• Sufferer unlikely to even mention it as a compulsion
because it is painful, overlooking that it is still a form of
checking and avoiding discomfort with uncertainty

28. SELF-PUNISHMENT
• The sufferer believes they have done something wrong or
committed some sort of unforgiveable error. To accept that
sometimes they do the wrong thing and move on would
mean tolerating the discomfort of feeling like they were
getting away with a crime. To account for this, they may
intentionally force feelings of guilt and negative self-
thoughts as a form of sentencing for their crime. Once they
have been adequately punished, they are more likely to feel
able to move on.

29. SELF-PUNISHMENT
• While this is obviously unpleasant, it is nonetheless
compulsive because it serves to avoid the discomfort of
feeling like they have escaped justice.
• Often overlooked as simply a product of perfectionism and
low self-esteem.
• Important to address as a voluntary behavior, separate
from the intrusive negative self-thoughts or cognitive
distortions.

30. MEMORY HOARDING
• As in physical hoarding, theOCD sufferer engaging in this
compulsion is going out of their way to save small bits of
information for potential recall. This often occurs at the
sacrifice of staying in the moment or enjoying anything for
fear of missing out on carefully storing an event in memory.
• Examples of this may involve compulsively memorizing
interactions with people or actively attending to
memorization of the details of a room or a book.

31. COMPULSIVE PRAYER
• For scrupulosity sufferers, prayer is often used to
counteract the intrusion of anti-religious or otherwise
unacceptable thoughts. Prayer becomes ritual when it is
used repeatedly to neutralize thoughts or evade them,
rather than as an attempt to more genuinely connect with
one’s religious faith.
• May also be engaged in as a form of thought neutralization
even when obsession is non-religious in content.

32. COUNTING
• The mental behavior of counting in a mathematical pattern
or of counting steps, objects, lines, etc. can come in two
forms.
• It can be its own compulsion, in which the OCD sufferer feels
the need to count to keep something bad from happening
• or it can be used as a form of compulsive avoidance by
counting instead of allowing other unwanted thoughts to
stay present.

33. MATHEMATICS
• Mentally reviewing the number of times an event
occurred and/or the dates of events in an attempt to
determine the severity of an event and self-reassure.
• For example, someone obsessing about their sexual
past may attempt to form in their mind a statistical
average of sexual partners over time in an attempt to
feel certain that they have not been promiscuous.

34. MENTAL CHANTING
• Mentally repeating words or phrases, whether
positive, neutral, or upsetting, by rote.
• May be done a certain number of times or
until a desired feeling or mood is established.
• Must be intentional and distinguished from
intrusive uncontrolled repetition of thoughts.

35. TREATMENT CONSIDERATIONS
• MINDFULNESS
• COGNITIVE RESTRUCTURING
• EXPOSUREWITH RESPONSE PREVENTION

36. MINDFULNESS
• Acceptance of presence of thoughts, feelings, and physical
sensations without judgment
• Developing skill of acknowledging and walking away from mental
rituals and toward the present
• Noticing urge to ritualize and accepting as part of present state
without responding
• Using meditation and “mindfulness in the moment” as practice
• “Noting” as a strategy for reducing mental ritual
• Purpose: increase awareness of when distracted and return to
present moment without further analysis

37. Cognitive Restructuring
• Identifying and challenging cognitive distortions – patterns of
thinking that promote ritualizing (i.e. all-or-nothing,
catastrophizing, emotional/magical reasoning)
• Not about disproving fears, but about disengaging from
“need” to ritualize by acknowledging uncertainty
• Important to keep brief and secondary in order to avoid
becoming a self-reassurance ritual
• Watch for “rationalizing”
• Positioning self as observer of thought process

38. EXPOSUREWITH RESPONSE
PREVENTION (ERP)
• Essential for all forms of OCD
• Include imaginal exposures (a.k.a. scripting) when in
vivo unrealistic (may be more effective to use fresh-
written scripts to avoid mental rituals instead of loop
tapes or repetitive reading scripts)
• Goal of triggering urge to ritualize for the purpose of
habituation and development of resistance skills

39. HAVINGTHOUGHTSVS
THINKING
• Having thoughts – the uncontrollable
appearance of an idea (thought, feeling,
sensation)
• Thinking – the voluntary behavior of
analyzing an idea (thought, feeling,
sensation)

40. BACKGROUND NOISE
• Some mental rituals may become an
automatic thought process that continues
despite treatment
• Focus on controlling the controllable and
accepting the uncontrollable

41. LABEL AND ABANDON
• Core concept of addressing mental rituals is to educate
sufferer to identify and label mental ritual as a behavior,
then abandon before completion (“OK, I’m reviewing,
don’t need to do this right now, walking away”)
• Expected consequence is feeling of incompleteness and
irresponsibility
• Goal is to catch and release sooner and with less effort
• NOT thought-stopping… ritual stopping!

42. Distraction
• Can be used compulsively or as a tool for
interfering in mental rituals
• Purposely interfering in ability to think by
confusing self during mental ritual with
competition – e.g. remembering lyrics to a
song or the sound of a 56k modem

43. Novel ERP Games
• GrandTheft Auto at the Mall ERP (purposely
opening up to all obsessive thoughts in a public
space without engaging in mental rituals)
• Exercise,The Exercise (purposely exposing to
obsessive thoughts during first half of an activity,
then employing distraction in second half)

44. FINALTHOUGHTS
• Therapists treating OCD must consider all rituals, not
just physical ones. Even when physical rituals are
properly addressed, sufferer may sublimate them with
mental ones and remain similarly impaired.
• Sometimes helpful to frame course of CBT as getting
the physical compulsions ceased and out of the way
for the purpose of addressing the mental ones that
bolster the obsession.

45. FINALTHOUGHTS
• Sufferers benefit from understanding mental
rituals as compulsions, a behavioral aspect of
obsessive compulsive disorder and not a
separate issue or diagnosis
• There is no “PURE O” beyond the name and
obsessions with primarily mental rituals are
equally treatable with CBT

46. references
• Williams, M.T., Farris, S. G.,Turkheimer, E., Pinto, A., Ozanick, K.,
Franklin, M. E., Simpson, H. B., Liebowitz, M., & Foa, E. B. (2011).
The Myth of the Pure ObsessionalType in Obsessive-Compulsive
Disorder. Depression & Anxiety, 28, 6, 495-500.
• Leonard, R.C. & Riemann, B.C.The co-occurrence of obsessions
and compulsions in OCD. Journal of Obsessive-Compulsive and
Related Disorders 2012;1:211-5.

47. contacts
• Jon Hershfield, MFT
– ocdbaltimore.com, jon@ocdbaltimore.com
• MonnicaWilliams, Ph.D.
– https://louisville.edu/psychology/williams,
m.williams@louisville.edu
• Elspeth Bell, Ph.D.
– Elspethbellphd.com, ebell@elspethbellphd.com
• Jeff Bell
– Beyondthedoubt.com, jeff@beyondthedoubt.com