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ACT for OCD: Why Problem Solving Obsessions Doesn’t Work

By Kate Morrison, Ph.D.

This video is part of our upcoming online course about ACT for OCD.

Highlights

  • Clients come into therapy seeing their obsessions as the problem and feeling stuck. 
  • Use metaphors to assess the client in noticing the problem-solving mindset.
  • Problem-solving can be a useful tool.
  • Problem-solving can be unhelpful and ineffective with internal experiences.

 

Transcript

Clients often come into therapy describing their internal experiences as the source of the problem, “So, if I didn’t have urges to do compulsions, then I wouldn’t do compulsions,” and a desire to really target this in therapy.

In order to determine the feasibility of altering their internal experiences, therapists can form a list of the strategies that have been tried to stop, control, or regulate those internal experiences. And through this exercise, they’ll likely see that what they view as the source of the problem is not changing and thus, the exercise that we’ve been talking about. And at this point, it can be useful to use metaphors that match the approach and the actions that they’re taking, but to explore it with the content that they’re not so entangled with.

References

Armstrong, A. B., Morrison, K. L., & Twohig, M. P. (2013). A preliminary investigation of acceptance and commitment therapy for adolescent obsessive-compulsive disorder. Journal of Cognitive Psychotherapy, 27(2), 175–190.

Morrison, K. L., Smith, B. M., Lee, E. B., & Twohig, M. P. (2017). Acceptance and commitment therapy for OC-spectrum disorders. In J. S. Abramowitz, D. McKay, & E. A. Storch (Eds.), The Wiley handbook of obsessive compulsive disorders (pp. 1175–1192). John Wiley & Sons, Inc.

So, metaphors that are commonly used to elucidate this point that the internal experiences cannot be removed or reduced permanently. There are some pretty common ones, like the plumber and the leaky pipe, tug of war with a monster, or a person in the hole. You can use a variety of these and see what fits best for your client. I’ll walk through the plumber and the leaky pipe so you can see an example of what that one might sound like.

References

Armstrong, A. B., Morrison, K. L., & Twohig, M. P. (2013). A preliminary investigation of acceptance and commitment therapy for adolescent obsessive-compulsive disorder. Journal of Cognitive Psychotherapy, 27(2), 175–190.

Morrison, K. L., Smith, B. M., Lee, E. B., & Twohig, M. P. (2017). Acceptance and commitment therapy for OC-spectrum disorders. In J. S. Abramowitz, D. McKay, & E. A. Storch (Eds.), The Wiley handbook of obsessive compulsive disorders (pp. 1175–1192). John Wiley & Sons, Inc.

Morrison, K. L., Smith, B. M., Ong, C. W., Lee, E. B., Friedel, J. E., Odum, A., Madden, G. J., Ledermann, T., Rung, J., & Twohig, M. P. (2019). Effects of acceptance and commitment therapy on impulsive decision-making. Behavior Modification, 44(4), 600–623.

So for this one, what I say to clients is, “We’re going to separate this from the OCD for a little bit. I want us to think totally separately from that. Set that aside for a moment. What we’re going to focus on is just watching what your mind does when I present you with some information.”

References

Armstrong, A. B., Morrison, K. L., & Twohig, M. P. (2013). A preliminary investigation of acceptance and commitment therapy for adolescent obsessive-compulsive disorder. Journal of Cognitive Psychotherapy, 27(2), 175–190.

Morrison, K. L., Smith, B. M., Lee, E. B., & Twohig, M. P. (2017). Acceptance and commitment therapy for OC-spectrum disorders. In J. S. Abramowitz, D. McKay, & E. A. Storch (Eds.), The Wiley handbook of obsessive compulsive disorders (pp. 1175–1192). John Wiley & Sons, Inc.

Morrison, K. L., Smith, B. M., Ong, C. W., Lee, E. B., Friedel, J. E., Odum, A., Madden, G. J., Ledermann, T., Rung, J., & Twohig, M. P. (2019). Effects of acceptance and commitment therapy on impulsive decision-making. Behavior Modification, 44(4), 600–623.

“So, I want you to imagine that you’re at your kitchen sink, and you notice that you have a leak. You have a pipe that is under your sink, and it starts to leak. What do you do?” And they’ll often say something like, “Oh, I’ll figure out what’s going on,” “I’ll put a bucket under it,” “I’d see if I can fix it, tighten something.” Or somebody’s like, “Oh, I have no idea what to do with that,” “I’d just call a plumber.” They start to problem solve.

References

Armstrong, A. B., Morrison, K. L., & Twohig, M. P. (2013). A preliminary investigation of acceptance and commitment therapy for adolescent obsessive-compulsive disorder. Journal of Cognitive Psychotherapy, 27(2), 175–190.

Morrison, K. L., Smith, B. M., Lee, E. B., & Twohig, M. P. (2017). Acceptance and commitment therapy for OC-spectrum disorders. In J. S. Abramowitz, D. McKay, & E. A. Storch (Eds.), The Wiley handbook of obsessive compulsive disorders (pp. 1175–1192). John Wiley & Sons, Inc.

Morrison, K. L., Smith, B. M., Ong, C. W., Lee, E. B., Friedel, J. E., Odum, A., Madden, G. J., Ledermann, T., Rung, J., & Twohig, M. P. (2019). Effects of acceptance and commitment therapy on impulsive decision-making. Behavior Modification, 44(4), 600–623.

Then you say, “Okay. Great. So, you tried it yourself. You called the plumber and then it works. It stops the leak for, let’s say, a day. And then the next day, you look and—ah! It’s leaking again. Now, what do you do?”

And they’d say, “Well, probably call the plumber back,” or, “I’d call a friend or somebody that knows how to do this,” and then they’d try to fix it again.

So I’m like, “Okay. Great. Makes sense. Okay. This time, it worked for 2 days. The leak stopped, but then a couple of days later, it’s leaking again. Now, what do we do?”

References

Armstrong, A. B., Morrison, K. L., & Twohig, M. P. (2013). A preliminary investigation of acceptance and commitment therapy for adolescent obsessive-compulsive disorder. Journal of Cognitive Psychotherapy, 27(2), 175–190.

Morrison, K. L., Smith, B. M., Lee, E. B., & Twohig, M. P. (2017). Acceptance and commitment therapy for OC-spectrum disorders. In J. S. Abramowitz, D. McKay, & E. A. Storch (Eds.), The Wiley handbook of obsessive compulsive disorders (pp. 1175–1192). John Wiley & Sons, Inc.

Morrison, K. L., Smith, B. M., Ong, C. W., Lee, E. B., Friedel, J. E., Odum, A., Madden, G. J., Ledermann, T., Rung, J., & Twohig, M. P. (2019). Effects of acceptance and commitment therapy on impulsive decision-making. Behavior Modification, 44(4), 600–623.

And you keep walking through this step by step by step. And just keep asking, “Okay, then what do you do?” “Then what do you do?” “Then what do you do?” And at some point, people get like, “Well, I’ll just move into another house,” or, “I would hire a completely different plumber,” or, “I’d replace the entire sink.” You start to notice some frustration, and like they’re hitting their limits of knowing what to do with this. And the thing is, you always want to come back saying, “Okay. And it’s leaking again.”

References

Armstrong, A. B., Morrison, K. L., & Twohig, M. P. (2013). A preliminary investigation of acceptance and commitment therapy for adolescent obsessive-compulsive disorder. Journal of Cognitive Psychotherapy, 27(2), 175–190.

Morrison, K. L., Smith, B. M., Lee, E. B., & Twohig, M. P. (2017). Acceptance and commitment therapy for OC-spectrum disorders. In J. S. Abramowitz, D. McKay, & E. A. Storch (Eds.), The Wiley handbook of obsessive compulsive disorders (pp. 1175–1192). John Wiley & Sons, Inc.

Morrison, K. L., Smith, B. M., Ong, C. W., Lee, E. B., Friedel, J. E., Odum, A., Madden, G. J., Ledermann, T., Rung, J., & Twohig, M. P. (2019). Effects of acceptance and commitment therapy on impulsive decision-making. Behavior Modification, 44(4), 600–623.

And what you’re matching up here is their attempts to problem solve something like a leaky pipe, you want to match that up with their attempts to problem solve something like an obsession.

So the leaky pipe here represents obsessions that no matter what they do, no matter how they try, how hard they try, that thing just keeps coming back.

References

Armstrong, A. B., Morrison, K. L., & Twohig, M. P. (2013). A preliminary investigation of acceptance and commitment therapy for adolescent obsessive-compulsive disorder. Journal of Cognitive Psychotherapy, 27(2), 175–190.

Morrison, K. L., Smith, B. M., Lee, E. B., & Twohig, M. P. (2017). Acceptance and commitment therapy for OC-spectrum disorders. In J. S. Abramowitz, D. McKay, & E. A. Storch (Eds.), The Wiley handbook of obsessive compulsive disorders (pp. 1175–1192). John Wiley & Sons, Inc.

Morrison, K. L., Smith, B. M., Ong, C. W., Lee, E. B., Friedel, J. E., Odum, A., Madden, G. J., Ledermann, T., Rung, J., & Twohig, M. P. (2019). Effects of acceptance and commitment therapy on impulsive decision-making. Behavior Modification, 44(4), 600–623.

And so what you can discuss with them is, from this point, it’s useful for our minds to problem solve. When we have a leaky pipe, that’s a super helpful thing for our minds to do. If we have a flat tire and we need to get to work, we need our mind to be able to problem solve to figure out either how to fix the flat tire or how to take a train, something that’s going to still get us to our work. But the problem can be when our minds try to use that same strategy of problem solving to fix what it defines as a problem that’s going on inside.

References

Armstrong, A. B., Morrison, K. L., & Twohig, M. P. (2013). A preliminary investigation of acceptance and commitment therapy for adolescent obsessive-compulsive disorder. Journal of Cognitive Psychotherapy, 27(2), 175–190.

Morrison, K. L., Smith, B. M., Lee, E. B., & Twohig, M. P. (2017). Acceptance and commitment therapy for OC-spectrum disorders. In J. S. Abramowitz, D. McKay, & E. A. Storch (Eds.), The Wiley handbook of obsessive compulsive disorders (pp. 1175–1192). John Wiley & Sons, Inc.

Morrison, K. L., Smith, B. M., Ong, C. W., Lee, E. B., Friedel, J. E., Odum, A., Madden, G. J., Ledermann, T., Rung, J., & Twohig, M. P. (2019). Effects of acceptance and commitment therapy on impulsive decision-making. Behavior Modification, 44(4), 600–623.

So if it defines an obsession as a problem, it’s going to start problem solving because that’s what it knows how to do. So you really want to highlight here for clients that this is not a problematic thing that their mind is doing. We just want to notice this process and see if it’s working for them because their minds, all of our minds, are really good at problem solving, but it’s just choosing a task that maybe doesn’t work the same way as something like a flat tire.

References

Armstrong, A. B., Morrison, K. L., & Twohig, M. P. (2013). A preliminary investigation of acceptance and commitment therapy for adolescent obsessive-compulsive disorder. Journal of Cognitive Psychotherapy, 27(2), 175–190.

Morrison, K. L., Smith, B. M., Lee, E. B., & Twohig, M. P. (2017). Acceptance and commitment therapy for OC-spectrum disorders. In J. S. Abramowitz, D. McKay, & E. A. Storch (Eds.), The Wiley handbook of obsessive compulsive disorders (pp. 1175–1192). John Wiley & Sons, Inc.

Morrison, K. L., Smith, B. M., Ong, C. W., Lee, E. B., Friedel, J. E., Odum, A., Madden, G. J., Ledermann, T., Rung, J., & Twohig, M. P. (2019). Effects of acceptance and commitment therapy on impulsive decision-making. Behavior Modification, 44(4), 600–623.

And so when you’re talking about it as a leaky sink or a leaky pipe, you’re helping them see, “Okay, this thing keeps coming back.” And we might be hitting our limits of this thing our brain knows how to do. And we don’t have to do anything from that point. You want them to just start noticing this process of problem-solving that their mind is doing all day.

References

Armstrong, A. B., Morrison, K. L., & Twohig, M. P. (2013). A preliminary investigation of acceptance and commitment therapy for adolescent obsessive-compulsive disorder. Journal of Cognitive Psychotherapy, 27(2), 175–190.

Morrison, K. L., Smith, B. M., Lee, E. B., & Twohig, M. P. (2017). Acceptance and commitment therapy for OC-spectrum disorders. In J. S. Abramowitz, D. McKay, & E. A. Storch (Eds.), The Wiley handbook of obsessive compulsive disorders (pp. 1175–1192). John Wiley & Sons, Inc.

Morrison, K. L., Smith, B. M., Ong, C. W., Lee, E. B., Friedel, J. E., Odum, A., Madden, G. J., Ledermann, T., Rung, J., & Twohig, M. P. (2019). Effects of acceptance and commitment therapy on impulsive decision-making. Behavior Modification, 44(4), 600–623.

So you’ll have a strong understanding of their OCD symptoms after your intake appointment and after completing the creative hopelessness exercise. But if there are symptoms that need more clarity, now is a good time to assess that further. And you want to make sure to understand the context in which these OCD symptoms occur.

References

Armstrong, A. B., Morrison, K. L., & Twohig, M. P. (2013). A preliminary investigation of acceptance and commitment therapy for adolescent obsessive-compulsive disorder. Journal of Cognitive Psychotherapy, 27(2), 175–190.

Morrison, K. L., Smith, B. M., Lee, E. B., & Twohig, M. P. (2017). Acceptance and commitment therapy for OC-spectrum disorders. In J. S. Abramowitz, D. McKay, & E. A. Storch (Eds.), The Wiley handbook of obsessive compulsive disorders (pp. 1175–1192). John Wiley & Sons, Inc.

Morrison, K. L., Smith, B. M., Ong, C. W., Lee, E. B., Friedel, J. E., Odum, A., Madden, G. J., Ledermann, T., Rung, J., & Twohig, M. P. (2019). Effects of acceptance and commitment therapy on impulsive decision-making. Behavior Modification, 44(4), 600–623.

So, some key points here are that clients are often coming into therapy seeing their obsessions as the problem and can feel stuck because they cannot fix this problem. Using metaphors, you can assess the client in noticing the problem-solving mindset that is being applied.

And then you want to show them how problem-solving can be a useful tool and also how it can be unhelpful and ineffective when it’s going toward our internal experiences.

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