Obsessions, Compulsions, OCD and Internal Family Systems

Join Dr. Peter to go way below the surface and find the hidden meanings of obsessions, compulsions and OCD.  Through poetry and quotes, he invites you into the painful, distressing, fearful and misunderstood world of those who suffer from OCD.  He defines obsessions and compulsions, discusses the different types of each, and evaluates two conventional treatments and one alternative treatment for OCD.  Most importantly, he discusses the deepest natural causes of OCD, which are almost always disregarded in conventional treatment, which focuses primarily on the symptoms.  
Lead-in
 OCD is not a disease that bothers; it is a disease that tortures. - Author: J.J. Keeler

  “It can look like still waters on the outside while a hurricane is swirling in your mind.” — Marcie Barber Phares

 Poetry or word picture (prayer of the scrupulous)

 Aditi Apr 2017

 

Obsessive Compulsive Disorder.  OCD.  That is what we are addressing today. Here is what OCD is like for Toni Neville -- she says:  “It’s like being controlled by a puppeteer. Every time you try and just walk away he pulls you back. Are you sure the stove is off and everything is unplugged? Back up we go. Are you sure your hands are as clean as they can get? Back ya go. Are you sure the doors are securely locked? Back down we go. How many people have touched this object? Wash your hands again.” 

Introduction
 We are together in this great adventure, this podcast, Interior Integration for Catholics, we are journeying together, and I am honored to be able to spend this time with you.  

I am Dr. Peter Malinoski, clinical psychologist and passionate Catholic and together, we are taking on the tough topics that matter to you.  

We bring the best of psychology and human formation and harmonize it with the perennial truths of the Catholic Faith.   

Interior Integration for Catholics is part of our broader outreach, Souls and Hearts bringing the best of psychology grounded in a Catholic worldview to you and the rest of the world through our website soulsandhearts.com

 Today, we are getting into obsessions and compulsions -- a really deep dive into what's really going on with these experiences.  I know many of you were expecting me to discuss scrupulosity today -- And you know what?  I was expecting I would be discussing scrupulosity well, but in order to have that discussion of scrupulosity  be well-founded, we really need to get into understanding obsessions and compulsions first.  I have to bring you up to speed on obessions and compulsions before we get into scrupulosity, and there is a lot to know

The questions we will be covering about obsessions and compulsions.
 What are Obsession and Compulsions? Getting into definitions.  
Also What are the different types of obsessions and compulsions, the different forms that obsessions and compulsions can take
What is the experience of OCD like?  From those who have suffered it.  

Who suffers from obsessions and compulsions -- how common are they?  Who is at risk?

 Why do obsessions and compulsions start and why do they keep going?

 How do we overcome obsessions and compulsions?  How do we resolve them?  
What does the secular literature say are the best treatments"  -- Medication and a particular kind of therapy called Exposure and Response Prevention
Alternatives  
Can we find not just a descriptive diagnosis, but a proscriptive conceptualization that gives a direction for healing, resolving the obsessions and compulsions  Not just symptom management.

Definitions
 
Obsessions
 
DSM-5: Obsessions are defined by (1) and (2):
 Recurrent and persistent thoughts, urges, or impulses that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress.

 The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion).

 Not pleasurable

 
Involuntary
 My compulsive thoughts aren't even thoughts, they're absolute certainties and obeying them isn't a choice. - Author: Paul Rudnick

 To resist a compulsion with willpower alone is to hold back an avalanche by melting the snow with a candle. It just keeps coming and coming and coming. - Author: David Adam

 

Individual works to neutralize the obsession with another thought or a compulsion.  

From the International OCD Foundation:  Obsessions are thoughts, images or impulses that occur over and over again and feel outside of the person’s control. Individuals with OCD do not want to have these thoughts and find them disturbing. In most cases, people with OCD realize that these thoughts don’t make any sense.  Obsessions are typically accompanied by intense and uncomfortable feelings such as fear, disgust, doubt, or a feeling that things have to be done in a way that is “just right.” In the context of OCD, obsessions are time consuming and get in the way of important activities the person values. 

Common Obsessions
 
Sources
 What is OCD? Article by the International OCD Foundation on their website

 WebMD article How Do I Know if I Have OCD? By Danny Bonvissuto February 19. 2020

 Northpointrecovery.com blog What Types of OCD Are There? Get the Breakdown Here by the Northpoint Staff from May 3, 2019

 Article entitled Common Types of OCD: Subtypes, Their Symptoms and the Best Treatment by Patrick Carey dated July 6, 2021 on treatmyocd.com

 

Contamination
 Body fluids --- blood, urine, saliva, feces -   I gave my baby niece a serious illness when I held her --  I'm sure I got a disease from using the public restroom.  

Germs for communicable diseases -- may be afraid to shake hands, worried about catching gonorrhea

 Environmental contaminants -- radiation, asbestos

 Household chemicals -- cleaners, solvents

 Dirt

 If you put the wrong foods in your body, you are contaminated and dirty and your stomach swells. Then the voice says, Why did you do that? Don't you know better? Ugly and wicked, you are disgusting to me. - Author: Bethany Pierce

 
Losing Control
 Giving in to an impulse to harm yourself --  I could jump in front of this bus right now.  

Fear of acting on an impulse to harm others -- what if I stabbed my child with this knife?

 Fear of violent or horrific images in your mind 

Fear of shouting out insults or obscenities -- 

Fear of stealing things

 
Harm
 Fear of being responsible for some terrible event (causing a fire at an office building)

 Fear of harming others because of not being careful enough (leaving a stick in your yard that fell from a tree in a wind storm that may trip and hurt an neighbor child)

 
Relationships
 Doubts about romantic partner -- is she the right one for me?  Is there a better one I am supposed to find?  What if we are not meant to be together, but we wind up marrying each other? 

Is my partner faithful?

 
Unwanted Sexual Thoughts
 Forbidden or perverse sexual thoughts or images

 Sexual obsessions involving children

 Obsessions about aggressive sexual behavior toward others

 
Obsessions related to perfectionism
 Concern about evenness or exactness

 
need for things to be in their place
 Arranging things in a particular way before leaving home

 

Concern with a need to know or remember

 Inability to decide whether to keep or discard things

 Fear of losing things

 Fear of making a mistake -- may need excessive encouragement from others

 Needing to make sure that your action is just right -- I need to start this email over, something is not wright with the wording.  

Obsessions about your Sexual Orientation
Obsessions about being embarrassed in a public situation
Getting a non-communicable disease such as cancer
Superstitious ideas such as unlucky numbers or certain colors
Religious Obsessions (Scrupulosity)
 Concern with offending God

 Concerns about blasphemy

 Concerns about right and wrong, morality.

 

Compulsions
 
Definitions
 
DSM-5 Compulsions are defined by (1) and (2):
 Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.

 The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive.

 Most people with OCD have both obsessions and compulsions.  

From the International OCD Foundation
 Compulsions are the second part of obsessive compulsive disorder. These are repetitive behaviors or thoughts that a person uses with the intention of neutralizing, counteracting, or making their obsessions go away. People with OCD realize this is only a temporary solution but without a better way to cope they rely on the compulsion as a temporary escape. Compulsions can also include avoiding situations that trigger obsessions. Compulsions are time consuming and get in the way of important activities the person values.

 

Common Compulsions in OCD
 
Sources
 What is OCD? Article by the International OCD Foundation on their website

 WebMD article How Do I Know if I Have OCD? By Danny Bonvissuto February 19. 2020

 Northpointrecovery.com blog What Types of OCD Are There? Get the Breakdown Here by the Northpoit Staff from May 3, 2019

 Article entitled Common Types of OCD: Subtypes, Their Symptoms and the Best Treatment by Patrick Carey dated July 6, 2021

 

Washing and Cleaning
 Washing hands excessively or in a certain way

 Excessive showering, bathing, toothbrushing, grooming

 Cleaning items or objects excessively

 
Checking
 Checking that you did not or will not harm anyone

 Checking that you did not or will not harm yourself

 Checking that nothing terrible happened

 Checking that you did not make a mistake

 Checking specific parts of your body

 
Repeating
 Re-reading or re-writing

 
Repeating routine activities
 Going in and out of doors

 Getting up and down from chairs

 

Repeating body movements
 Tapping

 Touching

 Blinking

 

Repeating activities in multiples
 Doing things three times, because three is a good, right or safe number

 

Mental Compulsions
 Mental review of events to prevent harm (to oneself others, to prevent terrible consequences)

 Praying to prevent harm (to oneself others, to prevent terrible consequences)

 Counting while performing a task to end on a “good,” “right,” or “safe” number

 Cancelling” or “Undoing” (example: replacing a “bad” word with a “good” word to cancel it out)

 
 Putting things in order or arranging things until it “feels right” or are in perfect symmetry
Telling asking or confessing to get reassurance
Avoiding situations that might trigger your obsessions 

Obsessions and Compulsions go together
 
The vicious cycle of OCD -- Obsessive-Compulsive Disorder (OCD) at helpguide.org
 Obsessive thought  --  I could stab my nephew with this knife.

 Anxiety -- that would be a terrible thing to happen, I can't let that happen

 Compulsion -- Locking all the knives away, checking to make sure they are all accounted for when your sibling and her family are visiting

 Temporary relief -- the knives are all there.  “A physical sensation crawls up my arm as I avoid compulsions. But if I complete it, the world resets itself for a moment like everything will be just fine. But only for a moment.” —  Mardy M. Berlinger

Harm Obsession  
  Compulsion:  Keeping all knives hidden away somewhere
What if I killed my nephew and I just can’t remember?  Repeatedly going back to check if you ran someone over

DSM-5 Obsessive-Compulsive Disorder
 Presence of obsessions, compulsions, or both:

 The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

 The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

 The disturbance is not better explained by the symptoms of another mental disorder

 
Specify if:
 With good or fair insight: The individual recognizes that obsessive-compulsive disorder beliefs are definitely or probably not true or that they may or may not be true.

 With poor insight:  The individual thinks obsessive-compulsive disorder beliefs are probably true.

 With absent insight/delusional beliefs: The individual is completely convinced that obsessive-compulsive disorder beliefs are true. 4%

 With Tic disorder up to 30%

 

What is the experience of OCD
 Poem By Forti.no

 
Quotes:
 “You lose time. You lose entire blocks of your day to obsessive thoughts or actions. I spend so much time finishing songs in my car before I can get out or redoing my entire shower routine because I lost count of how many times I scrubbed my left arm.” — Kelly Hill

 “Ever seen ‘Inside Out’? With OCD, it’s like Doubt has its own control console.” — Josey Eloy Franco

 “Imagine all your worst thoughts as a soundtrack running through your mind 24/7, day after day.” — Adam Walker Cleveland

 “Picture standing in a room filled with flies and pouring a bottle of syrup over yourself. The flies constantly swarm about you, buzzing around your head and in your face. You swat and swat, but they keep coming. The flies are like obsessional thoughts — you can’t stop them, you just have to fend them off. The swatting is like compulsions — you can’t resist the urge to do it, even though you know it won’t really keep the flies at bay more than for a brief moment.” — Cheryl Little Sutton

 “It’s like you have two brains — a rational brain and an irrational brain. And they’re constantly fighting.” — Emilie Ford

 

Who
 12 month prevalence is 1.2% with international prevalence rates from 1.1 to 1.8%  NIH Women have a higher prevalence 1.8% than men 0.5%.  Males more affected in childhood.  Lifetime prevalence 2.3%

 
Risk Factors:
 
DSM-5
 
Temperamental Factors
 Greater internalizing symptoms

 Higher negative emotionality

 Behavioral inhibition

 

Environmental Factors
 Childhood physical abuse

 Childhood sexual abuse

 Other stressful or traumatic events

 

Genetic
 Monozygotic concordance rates --.57

 Dizygotic concordance rates .22

 

Physiological 
Dysfunction in the orbitofrontal cortex, anterior cingulate cortex, and striatum have been implicated.  
Streptococcal infection can precede the development of OCD symptoms in children

Therapy
 
Exposure and Response Prevention (ERP) -- Developed originally in the 1970s Stanley Rachman's work
 a type of behavioral therapy 
that exposes the person to situations that provoke their obsessions
causing distress, usually anxiety which leads to 
the urge to engage in the compulsion 
that gives them the temporary relief.  

The goal of ERP is to break the cycle of obsessions --> anxiety --> compulsion --> temporary relief.  So you are exposed to you anxiety provoking stimulus, and have the obsession, but you prevent the compulsive response, and you don't get the temporary relief. 
Basic premise: As individuals confront their fears and no longer engage in their escape response, they will eventually reduce their anxiety.
The goal is to habituate, or get used to the feelings of the obsessions, without having to engage in the compulsive behavior.  This increases the capacity to handle discomfort and anxiety.  Then one is no longer reinforced by the temporary anxiety relief that the compulsion provides.  

Patrick Carey writes that: Any behavior that engages with the obsession– e.g. asking for reassurance, avoidance, rumination– reinforces it. By preventing these behaviors, ERP teaches people that they can tolerate their distress without turning to compulsions. It thereby drains obsessions of their power. 

Division 12 of the APA

 

Essence of therapy: Individuals with OCD repeatedly confront the thoughts, images, objects, and situations that make them anxious and/or start their obsessions in a systematic fashion, without performing compulsive behaviors that typically serve to reduce anxiety. Through this process, the individual learns that there is nothing to fear and the obsessions no longer cause distress.

From the IOCDF : 
With ERP, the difference is that when you make the choice to confront your anxiety and obsessions you must also make a commitment to not give in and engage in the compulsive behavior. When you don’t do the compulsive behaviors, over time you will actually feel a drop in your anxiety level. This natural drop in anxiety that happens when you stay “exposed” and “prevent” the compulsive “response” is called habituation.
Instead, a person is forced to confront their obsessive thoughts relentlessly. The goal is to make the sufferer so accustomed to their obsessions that they no longer feel tempted to engage in soothing compulsions.

Types of Exposure -- GoodTherapy.org article
 Imaginal Exposure: In this type of exposure, a person in therapy is asked to mentally confront the fear or situation by picturing it in one's mind. For example, a person with agoraphobia, a fear of crowded places, might imagine standing in a crowded mall.

 In Vivo Exposure: When using this type of exposure, a person is exposed to real-life objects and scenarios. For example, a person with a fear of flying might go to the airport and watch a plane take off.

 Virtual Reality Exposure: This type of exposure combines elements of both imaginal and in vivo exposure so that a person is placed in situations that appear real but are actually fabricated. For example, someone who has a fear of heights—acrophobia—might participate in a virtual simulation of climbing down a fire escape.

 
Steven Pence, and colleagues in a 2010 article in the American Journal of Psychotherapy:  "When exposures go wrong: Troubleshooting guidelines for managing difficult scenarios that arise in Exposure-based treatment for Obsessive-Compulsive Disorder
 The present article reviews five issues that occur in therapy but have been minimally discussed in the OCD treatment literature: 

1) when clients fail to habituate to their anxiety -- they don't calm down

2) when clients misjudge how much anxiety an exposure will actually cause

3) when incidental exposures happen in session -- other fears in the fear hierarchy intrude.  

4) when mental or covert rituals interfere with treatment -- covert compulsive behaviors

5) when clients demonstrate exceptionally high anxiety sensitivity. 

Stacey Smith Counseling at stacysmithcounseling.com -- ERP failures
 Utilizing safety behaviors

 Not sitting with the anxiety until it dissipates -- distracting yourself

 Not working through all the irrational, unhelpful thoughts

 Not practicing often enough.  

ERP criticisms
 
Can be really unpleasant for clients -- repeated exposures to terrifying stimuli -- can there be a better way?
 Concerns about safety and security

 
Concerns about flooding with anxiety
 
Ben Blum: Inside the Revolutionary Treatment That Could Change Psychotherapy Forever  elemental.medium.com July 21, 2020
 Robert Fox is haunted by a memory of a germophobic woman with OCD whom he met once while she was hospitalized. As part of her ERP therapy, the therapists took her into the bathroom and had her wipe her hands over the toilet and sink and then rub them through her hair. She wasn’t permitted to shower until the next morning.

 

Concerns about dropout rates.  
Dropout rate of 18.7% across 21 ERP studies with 1400 participants Clarissa Ong and colleagues in 2016 article in the Journal of Anxiety Disorders
Dropout rate of 10% among youth for ERP in a 2019 meta-analysis by Carly Johnco and her colleagues in the Journal "Depression and Anxiety" 11 randomized trials

I'm concerned that it doesn't go deep enough 
Not getting to root causes -- staying at the symptom level -- seeing symptoms as nonsensical
 One thing which I can't stress enough is that OCD is completely nonsensical and will not listen to reason. This is one of the most frightening things about having it. I knew that to anyone I told, there are Salvador Dali paintings that make more sense. - Author: Joe Wells

 
What is the fear really about.  Let's not just ignore it.  Fear is a response to something.
Tracing back layers, going back through grief and anger, all the way to shame. 
Shame episodes 37-49.  
Doesn’t get to any spiritual issues

Medication
 
International OCD Foundation
 Drugs and dosages High doses are often needed for these drugs to work in most people.

 
Research suggests that the following doses may be needed:
  fluvoxamine (Luvox®) – up to 300 mg/day

 fluoxetine (Prozac®) – 40-80 mg/day

 sertraline (Zoloft®) – up to 200 mg/day

  paroxetine (Paxil®) – 40-60 mg/day

  citalopram (Celexa®) – up to 40 mg/day*

  clomipramine (Anafranil®) – up to 250 mg/day

 escitalopram (Lexapro®) – up to 40 mg/day

  venlafaxine (Effexor®) – up to 375 mg/day

 

How Do These Medications Work?  From the International OCD Foundation.  It remains unclear as to how these particular drugs help OCD. The good news is that after decades of research, we know how to treat patients, even though we do not know exactly why our treatments work. We do know that each of these medications affect a chemical in the brain called serotonin. Serotonin is used by the brain as a messenger. If your brain does not have enough serotonin, then the nerves in your brain might not be communicating right. Adding these medications to your body can help boost your serotonin and get your brain back on track.

 

Discussion of conventional approaches 
Medication
 
I am not a physician -- I'm a psychologist and I don't have prescription privileges
 I don't give advice on medication choices or on dosages or anything like that. 

If you think your medication is helping your OCD, I'm not going to argue with you about that --  I don't want to try to dissuade anyone from taking medication for psychological issues if they think it's helping them.  

Here's the thing, though.  So much of your thinking about medication depends on what you see as the cause of the problem
 It makes sense to take medication if you think the obsessions and compulsions pop up because of chemical imbalances.   You take the medication to restore the chemical balance and reduce the symptoms.

 So many of treatments for OCD treat the obsessions and compulsions as meaningless, as irrational, as just the random epiphenomena of consciousness, or just as nonsensical expressions of miswiring in the brain or just the effects of poorly balanced neurochemical in the brain.    

And so these approaches, like ERP that and medication that target the obsessions and compulsions for eradication, that seek to vanquish them result in multiple problems

 I think that is a major, major mistake.  

And here is what I want to emphasize.  Obsessions and Compulsions are symptoms.  They are symptoms.  Obsessions and compulsions, as painful and as debilitating as they are for many people, those obsessions and compulsions are not the primary problem.  They are the effects of the primary problem.  Obsessions and compulsions happen late in the causal chain.  I see meaning in every obsession and in every compulsion.  I see a message in every obsession and compulsion.  A cry for help, a signal of deeper distress.  

There are cases in which a psychological problem can be purely or primarily organic -- due to a medical condition -- for example due to head trauma that causes brain damage.  Or a brain tumor on the pituitary gland that disrupts your whole endocrine system, resulting in mood swings. But, Most of the time, though, psychological symptoms have psychological causes.  

As a Catholic psychologist, I want to move much further back in the causal chain.  I want to address and resolve the underlying issues that give rise to the obsessions in the first place.

 

Self Help  Obsessive-Compulsive Disorder (OCD) at helpguide.org
 
Identify your triggers
 Can help you anticipate your urges

 Create a solid mental picture and then make a mental note. Tell yourself, “The window is now closed,” or “I can see that the oven is turned off.”

 When the urge to check arises later, you will find it easier to re-label it as “just an obsessive thought.”

 

Learn to resist OCD compulsions
 by repeatedly exposing yourself to your OCD triggers, you can learn to resist the urge to complete your compulsive rituals --  exposure and response prevention (ERP)

 Build your fear ladder -- working your way up to more and more frightening things.  
Resist the urge to do your compulsive behavior
The anxiety will fade
You're not going to lose control or have a breakdown
Practice

Challenge Obsessive thoughts
 Thoughts are just thoughts

 
Write down obsessive thoughts and compulsions
 Writing it all down will help you see just how repetitive your obsessions are.

 Writing down the same phrase or urge hundreds of times will help it lose its power.

 Writing thoughts down is much harder work than simply thinking them, so your obsessive thoughts are likely to disappear sooner.

 

Challenge your obsessive thoughts. Use your worry period to challenge negative or intrusive thoughts by asking yourself
 What’s the evidence that the thought is true? That it’s not true? Have I confused a thought with a fact?

  Is there a more positive, realistic way of looking at the situation?

 What’s the probability that what I’m scared of will actually happen? If the probability is low, what are some more likely outcomes?

  Is the thought helpful? How will obsessing about it help me and how will it hurt me?

  What would I say to a friend who had this thought?

 

Create an OCD worry period. Rather than trying to suppress obsessions or compulsions, develop the habit of rescheduling them.
 Choose one or two 10-minute “worry periods” each day, time you can devote to obsessing.

 During your worry period, focus only on negative thoughts or urges. Don’t try to correct them. At the end of the worry period, take a few calming breaths, let the obsessive thoughts go, and return to your normal activities. The rest of the day, however, is to be designated free of obsessions.

 When thoughts come into your head during the day, write them down and “postpone” them to your worry period.

 
Create a tape of your OCD obsessions or intrusive thoughts. Focus on one specific thought or obsession and record it to a tape recorder or smartphone.
  Recount the obsessive phrase, sentence, or story exactly as it comes into your mind.

 Play the tape back to yourself, over and over for a 45-minute period each day, until listening to the obsession no longer causes you to feel highly distressed.

  By continuously confronting your worry or obsession you will gradually become less anxious. You can then repeat the exercise for a different obsession.

 
Reach our for support
 Stay connected to family and friends.

 Join an OCD support group. 

Manage Stress
 Quickly self-soothe and relieve anxiety symptoms by making use of one or more of your physical senses—sight, smell, hearing, touch, taste—or movement. You might try listening to a favorite piece of music, looking at a treasured photo, savoring a cup of tea, or stroking a pet.

 
Practice relaxation techniques. Mindful meditation, yoga, deep breathing, and other relaxation techniques can help lower your overall stress and tension levels and help you manage your urges. For best results, try practicing a relaxation technique regularly.
Lifestyle changes
 Exercise regularly

 Get enough sleep

 Avoid alcohol and nicotine

 
Not sure this is going to work.  Doesn't get to root causes.  

IFS as an alternative
 From Verywellmind.com  What is Internal Family Systems?  By Theodora Blanchfield, August 22, 2021

 

 What Is Internal Family Systems (IFS) Therapy?

 

Internal family systems, or IFS, is a type of therapy that believes we are all made up of several parts or sub-personalities. It draws from structural, strategic, narrative, and Bowenian types of family therapy.

 

The founder, Dr. Richard Schwartz, thought of the mind as an inner family and began applying techniques to individuals that he usually used with families. 

 

The underlying concept of this theory is that we all have several parts living within us that fulfill both healthy and unhealthy roles. Life events or trauma, however, can force us out of those healthy roles into extreme roles.

 

The good news is that these internal roles are not static and can change with time and work. The goal of IFS therapy is to achieve balance within the internal system and to differentiate and elevate the self so it can be an effective leader in the system. 

 

Parts:  Separate, independently operating personalities within us, each with own unique prominent needs, roles in our lives, emotions, body sensations, guiding beliefs and assumptions, typical thoughts, intentions, desires, attitudes, impulses, interpersonal style, and world view.  Each part also has an image of God and also its own approach to sexuality.  Robert Falconer calls them insiders. 
Robert Fox and Alessio Rizzo  have done the most work with IFS to work with obsessions and compulsions.   
Sources
 IFS and Hope with OCD with Alessio Rizzo and Robert Fox -- Episode 102 of Tammy Sollenberger's podcast The One Inside -- September 17, 2021

 Podcast IFS Talks:  Hosts Aníbal Henriques & Tisha Shull  A Talk with Robert Fox on OCD-types -- Robert Fox   February 20, 2021

 
Robert Fox, IFS therapist with OCD
 
Ben Blum: Inside the Revolutionary Treatment That Could Change Psychotherapy Forever  elemental.medium.com July 21, 2020
 https://elemental.medium.com/inside-the-revolutionary-treatment-that-could-change-psychotherapy-forever-8be035d54770

 

Robert Fox, a therapist in Woburn, Massachusetts, also wishes more people knew about IFS. Diagnosed with obsessive-compulsive disorder at age 21 after a lifetime of unusual compulsions, he spent 23 years receiving the standard care: cognitive behavioral therapy (CBT) and exposure response prevention (ERP). Neither had much effect, especially ERP, which involved repeatedly exposing himself to things he was anxious about in the hopes of gradually habituating to them.

 

“When you think about it, it’s a very painful method of therapy,” he says.

 

Fox discovered IFS in 2008. Before, he had always been encouraged to think of his compulsions as meaningless pathologies. Now, for the first time, they began making sense to him as the behavior of protectors who were trying to manage the underlying shame and fear of exiles.

 

After two particularly powerful unburdenings, his symptoms abated by 95% and stayed that way.

 

“[OCD] used to be almost like kryptonite around my neck when I would have serious flare-ups,” he says. “I feel a lot of freedom and peace and I really owe it to Dick [Schwartz] and the model.”

Concerns about ERP 
ERP doesn't bring the curiosity -- why did this happen?  
Obsessions are not irrational and Compulsions are not meaningless
Alessio Rizzo Conventional OCD diagnosis and treatment ERP and medication -- nothing points back to underlying causes.

Alessio Rizzo:  Evidence-based approaches for OCD that work -- they work by drawing a manager part into a role of suppressing OCD symptoms  Needing to continue ERP.  
Causes:  Fox
 Repressed anger. -- not a parent who could witness

 
Intense shame that is dissociated
 Shame from childhood -- exiled

 Shame from the OCD itself.  -- sarcasm from others, especially from his older brother.  
“OCD is like having a bully stuck inside your head and nobody else can see it.” — Krissy McDermott
 

We hide what we are ashamed of -- not easy to treat.

 
Fox on his treatment:  Right. I didn't see it myself until one day I was out for a walk with my dog Gizmo around my block, walking around the block with him and I had been to all these lectures about shame and I was walking one day and all of a sudden it was like, it just came to me “Holy, Holy, Holy shit. I carry that shame.” And it was like a dark cloud that was overhead and just kind of followed me wherever I went. And it was actually not an awful thing to realize. That's what had been basically walking around on my back for so long. It was this deep shame.
In agreement with how central I think shame is to OCD

Obsessions and compulsions develop gradually and experiment with different ways of drawing attention away from the intensity of underlying experience.  All happens in silence in the inner world.  
An obsession or compulsion distracts us from the pain of an exile.  If I'm worrying about the gas in the lawnmower overflowing and blowing up the house -- takes me away from the shame of feeling inadequate at work.  
Needs to be powerful enough to hijack my mind
So many layers of protectors  -- takes time

Alessio Rizzo Post dated March 3, 2021 entitled "IFS and OCD -- A Comparison Between CBT and IFS for OCD.  https://www.therapywithalessio.com/articles/ifs-and-ocd-how-does-the-ifs-method-work-for-ocd
 In IFS, we use the language of parts to describe how we function. As a consequence, the OCD is considered a part of the person. This means that, even if the OCD seems quite a strong presence in the client’s life, there is much more to a person than OCD.

 At this stage CBT and IFS might look similar because CBT also encourages clients to label the anxieties and the intrusive thoughts that form the OCD and not engage with them.

 The main difference between CBT and IFS is in how we relate to the OCD part. 

One of the foundational elements of IFS is that all parts are welcome, and, therefore, the OCD part is not dismissed or ignored, but it is respected. Respect does not mean that the client will believe the content of intrusive thoughts or that they will follow up on whatever behaviour the OCD wants. IFS gives us a way to make sure that there is enough safety and calm before offering respect to the OCD part. This might take a different amount of attempts depending on the severity of the OCD, and on the strength of the relationship between therapist and client.

 Healing OCD with IFS

 The main difference between CBT and IFS is in the definition of “cure” of OCD.

 CBT therapy has the ultimate goal of empowering the client to overcome OCD thoughts and anxieties by never engaging with them or by using exposure therapy to demonstrate that the OCD fears and obsessions have got no evidence to exist.

 IFS believes that healing is the result of the re-organisation of parts so that extreme behaviour is substituted by more functional ways of thinking and acting, and, above all, IFS aims at healing the traumatic events that have led to the development of OCD symptoms.

 

 

The result of healing the trauma that fuels OCD is a spontaneous decrease of OCD anxieties and intrusive thoughts and, in my opinion, this form of healing is preferable to the one described by CBT. Using IFS language, the CBT approach aims at creating a new part in the system that is tasked with managing the OCD, while there is no attention paid to discovery and healing of the trauma that is fueling the OCD.

Choosing the method that best suits you

 

There is no way of saying what method works best for a person. 

 

Therapy outcomes depend on many factors and not only on the method used. Sometimes the quality of the therapeutic relationship is the biggest healing factor, and it is ultimately up to the client to find the best combination of therapist and method that can best suit them.

Colleen West, LMFT LMFT  December 20 post on her website colleenwest.com  Treating OCD with Internal Family Systems Parts Work
 Just a word about treating OCD with IFS versus Exposure and Response Prevention (ERP). Treating obsessive and compulsive parts with IFS is diametrically opposed to treating it in the Exposure and Response Prevention, the most commonly recommended approach. IFS treats OCD parts as what they are--managers and fire fighters, they have jobs to do. If you can help the exiles underneath these protectors, there will be less need for the OCD behaviors. (This might be complicated if there are still constant stressors in the client's life, for which they need the protection.)

 

IFS does work, and I have successfully treated people with full blown OCD who now have about 5% of their original symptoms only during moments of high stress, and they do not consider themselves OCD anymore. These clients have been helped by taking SSRIs as well, which I will say more about below.

ERP works to suppress those same protectors that IFS seeks to understand/care for. It does "work", as people get a strategy for the thoughts that are driving them nuts, but the folks I know who have gone through this treatment find they have to do their 'homework' forever or the OCD comes back, and they always feel it threatening. In short, it is stressful, and the fight is never over.

For anyone doing ERP, they have to commit fully to that approach, the homework is hours a day, and one cannot be halfhearted about it or it won't work. The good thing about ERP is that it gives people some control, which they strongly desire, because they feel so powerless.

Next episode Episode 87, will come out on December 6, 2022
 Scrupulosity --  I have such a different take -- Scrupulosity is what happens with perfectionism and OCD get religion.   Spiritual and Psychological elements.  
In the last episode we really got into understanding perfectionism.  In this episode, we worked on really getting to know about obsessions and compulsions.  Next episode, we get much more into scrupulosity.  My own battle with scrupulosity.  
Remember, you as a listener can call me on my cell any Tuesday or Thursday from 4:30 PM to 5:30 PM.  I've set that time aside for you.  317.567.9594.  (repeat) or email me at [email protected]. 

Resilient Catholics Community.  Talked a lot about it in episode 84, two episodes ago.  We now have 106 on the waiting list.  Reopening the community on December 1 for those on the waiting list first.  Can learn a lot more about the RCC and you can sign up at soulsandhearts.com/rcc.  We have had heavy demand.  We may have to limit how many we bring in.  I am working to clear time in my calendar to review the Initial Measures Kits and help new members through the onboarding process -- all the individual attention takes time.  I'm also hiring more staff to help.  

Pray for me.  Humility.  Childlike trust  

Invocations