Learning About Compulsions

1 When someone becomes an expert at dancing, playing chess, being a doctor, programming a computer, playing a sport, or almost anything else, the person learns words that are helpful in thinking about how to do the activity well. This handout is meant to get you started in becoming an expert on how people get over compulsions. Unsurprisingly, it will go over the meanings of several words that are helpful in thinking about all this. It will also use those words to try to explain some very useful ideas.

In this section the author is letting you know that it's useful to

A. practice relaxation often,

B. learn and use some specialized words when you try to become an expert on something.

2 A compulsion is feeling the need to do something over and over, even though doing that behavior doesn't bring about anything pleasant or useful. Doing it over and over gets in the way of having fun and accomplishing things.

There are lots of things we do over and over that do bring about something pleasant or useful. These are not compulsions, but good ideas.

Someone has to count to 50 before taking a drink of anything. If they don't count right, they have to start all over. Do you think this is

A. A compulsion,

B. A good idea?

3 Before leaving the house in the morning, a man in the habit of checking, one time, to make sure he has his keys, his wallet with his driver's license, and his cell phone. He does this every morning. Do you think this is

A. A compulsion,

B. A good idea?

4 Another man, before leaving the house in the morning, checks to make sure the stove is turned off. But then he gets an uneasy feeling and checks another time. This goes on over and over. He really knows the stove is off, but he keeps checking just to be able not to worry about it. It works for a short time, but then he gets the uneasy feeling again. He spends so much time checking that he is often late to work. Do you think this is

A. A compulsion,

B. A good idea?

5 Someone wants to stay in good physical condition, so she tries to get some exercise every day. She has lots of different ways of getting exercise. She tries really hard not to have a day go by without exercise, because she has found she sleeps better if she gets exercise. But if she gets sick, she can break her rule about exercising every day, without feeling very bad about it.

A. A compulsion,

B. A good idea?

6 Another word for the behavior you do over and over in a compulsion is a ritual. (And sometimes people talk about compulsive rituals!) Someone has to smooth out the wrinkles in each piece of clothing they put on, in a certain way, each time they get dressed. If it doesn't feel right, they have to do it over. It takes the person a long time to get dressed because of this. You can call this

A. either a compulsion or a ritual or a compulsive ritual,

B. A good idea?

7 There are certain situations that trigger compulsions -- we might call them "trigger situations" for short. These are the situations that the compulsions are meant to avoid or somehow make better. If someone has a compulsion to keep adjusting their socks to make sure they are exactly the same height, the trigger situation is having the socks unequal in height. If someone has a compulsion to keep adjusting a picture to make sure that it's not crooked, the trigger situation is seeing the picture a little crooked.

If someone has a compulsion not to step on any cracks or lines in the sidewalk, walking along and stepping on cracks and lines is

A. a compulsion,

B. a trigger situation?

8 If a person has a compulsion to wash their hands any time they touch something someone else has touched, then having touched that thing is a trigger situation. If someone counts, but feels that they can't or shouldn't stop until they reach 50, then stopping at 37 is a trigger situation. If someone remembers something impolite that they said to someone years ago and feels a compulsion to confess to their parent and ask for reassurance that they are not a bad person, the trigger situation is remembering the impolite thing they did. The goal in working with trigger situations is to make them not so unpleasant, not to need to avoid them, and not to have them trigger compulsions. It's good to identify these situations, because these are the ones to learn to handle in a way you like better.

Why does the author talk about trigger situations?

A. Because you'll want to stay away from them.

B. Because you'll want to make them less unpleasant and not need to avoid or undo them.

9 Getting into a trigger situation is called an exposure. The person is exposed to the situation. Sometimes exposures happen because people can't avoid them. For example, someone can't avoid touching anything that might trigger the wish to wash the hands. At other times, exposures happen on purpose, because people want to practice and work on getting able to handle the trigger situation better. For example, someone with a compulsion to make the socks equal heights, makes one sock lower than the other on purpose.

Suppose someone has a compulsion to walk through a certain doorway 5 times rather than just once. What do we call it when the person gets into the trigger situation of having just walked through the doorway one time?

A. A ritual

B. An exposure?

10 Suppose the person feels a compulsion to wash their hands every time they touch their dog. Which of the following is an exposure?

A. The person pets the dog, but has not washed their hands.

B. The person doesn't pet the dog so they won't have to wash their hands.

11 Working on compulsions usually involves giving yourself exposures to trigger situations on purpose. Suppose someone needs to do a ritual every night of putting things in a certain place before going to sleep. But the person is invited to a sleepover that they want to go to. They know that they won't be able to have things in the room the same way when they go to the sleepover. So they deliberately move things around in their room before going to bed, so they can practice handling things being different.

Did this exposure happen

A. By chance,

B. On purpose?

12 Suppose the same person gets a strong urge to move the things in the room back to where the person feels they should be. But they don't let themselves do it. This is called "ritual prevention." The person is preventing themselves from doing the ritual. The person finds that after a while, they get used to things being in different places. It no longer bothers them so much that things are moved. Exposure and ritual prevention have reduced the person's compulsion, and if they keep practicing exposure and ritual prevention, the compulsion goes away! For this reason, people say that "exposure and ritual prevention" are the keys to getting rid of compulsions!

The keys to getting rid of compulsions are

A. Meditation and medication,

B. Exposure and ritual prevention?

13 Exposure and ritual prevention means just not doing the compulsion, even though you are in the trigger situation. The wonderful thing that people find is that they "get used to" the situation and they're able to be in it without it bothering them, the longer they stay in it. So the amount of pain or distress that and exposure and ritual prevention causes tends to get less, the more you do it, for any given compulsion. Very brief exposures aren't nearly as helpful as longer ones. With longer exposures, you have a chance to get used to the trigger situation.

What's the "wonderful thing" the author refers to in this section?

A. That the trigger situations get less bothersome and painful the more you practice being in them without doing the compulsion.

B. That practicing things, such as dance, music, or sports, in your imagination helps you do better at those in real life?

14 Someone has a compulsion to wash their hands every time they touch a computer keyboard. The person deliberately touches the keyboard but keeps themselves from washing their hands. True or false: Having touched the keyboard is an exposure, and not washing is ritual prevention.

A. True

B. False?

15 Someone has a compulsion to breathe in a certain way, different from how they usually breathe, just before they eat anything. What brings about an exposure for this person?

A. Starting to eat something, without breathing in that certain way.

B. Breathing in that certain way without eating anything?

16 The same person we just spoke about starts to eat something but doesn't let themselves do the unusual way of breathing first. They keep on eating without doing that certain way of breathing. What do the compulsion experts call it, that the person just breathed regularly?

A. Compulsion-busting,

B. Ritual prevention?

17 When a person's parent leaves for work, their child has a compulsion to have a certain number of hugs and to say "I love you" a certain number of times. What would be an example of exposure and ritual prevention for this compulsion?

A. The person gets their parent not to leave for work, but to stay home.

B. The person has one hug and one "I love you" and then goodbye. When the person gets the urge to repeat this over and over, they resist the urge.

18 Sometimes the behavior that's repeated over and over is avoiding doing something. For example, there's a certain item of clothing that someone feels like they can't wear. What would be an example of exposure and ritual prevention for this?

A. Put the clothing on (exposure) and resist the urge to take it off (ritual prevention).

B. Wait for a couple of years for the dislike of this type of clothing to go away.

19 After someone takes a shower, they have the compulsion to dry off every little bit of water that is left on their skin, before putting their clothes on. If the towel is damp, it doesn't feel right, so the person uses several dry towels. This takes up a lot of time. What would be an example of exposure and ritual prevention for this?

A. The person dries off with one towel, and purposely leaves a little drop of water on them (exposure). They resist the urge to keep drying, and go ahead and put their clothes on (ritual prevention).

B. The person just waits in the bathroom for all the water to evaporate before putting their clothes on, instead of using towels.

20 When someone does a successful exposure and ritual prevention, they have reason to feel really good! And it's a good idea for them to celebrate in their mind by saying things to themselves like, "Hooray for me! Yay! I did a courage triumph! I am proud of myself!" It's good for them to tell someone they trust about their triumph, so that the other person can feel good and celebrate with them.

When someone does a successful exposure and ritual prevention, it's good for them to

A. be very humble and modest,

B. to celebrate their accomplishment?

21 Why is it good to celebrate when one has a successful exposure and ritual prevention? Because we tend to do more often the things that bring us pleasure. If we can work ourselves up to feeling really good each time we do an exposure and ritual prevention, we feel more like doing the next one. And the more we do, the faster we get rid of the problems with compulsions!

What's the point of this section?

A. The more you can feel good about your courage triumphs in doing exposure and ritual prevention, the faster your progress will be!

B. Sometimes there are things that are pleasant, but we shouldn't do them; making the choice to do the right thing in these situations is called using self-discipline.

22 When you have a courage triumph and have used exposure and ritual prevention, there's another thing that is good to do: keep remembering your triumph! Remind yourself of what you did and how you did it. Each time you remember it, you are rehearsing doing an exposure and ritual prevention in your fantasy. And this makes it easier to do the next one.

What's the point of this section?

A. If you keep reminding yourself of your successes, this helps you to do more of them, because you are really practicing in your mind.

B. Rehearsing behaviors in fantasy is used a lot by sports competitors to help them do better performances.

23 Suppose that someone has 20 different compulsions that they want to get rid of. It's often a good idea not to try to do exposure and ritual prevention with all of them at once. It takes energy to do exposure and ritual prevention, and it's usually a good idea to work on one or a few compulsions at a time, so the demands on your energy aren't too overwhelming.

Someone decides to keep doing the compulsive rituals for some of their compulsions, for a while, in order to save their energy to do ritual prevention with others. The author thinks that:

A. This is a bad idea, because you never want to practice doing compulsions.

B. This is usually a good idea, because the goal of resisting every single ritual is often too much to take on all at once.

24 If you're going to work on compulsions one by one, what order should you go in? Most of the time it's best to start with compulsions that have a lower SUD level, and work your way up to the ones that have a higher SUD level. What's a SUD level? It's how bad it feels to be in the trigger situation without doing the ritual. People usually rate their SUD levels on a scale of 0 to 10 or 0 to 100, where the higher numbers are worse. SUD stands for "Subjective Units of Distress." Subjective means "How does it feel to you," rather than "How is it measured with some device?"

Does it feel better to have

A. A higher SUD level,

B. A lower SUD level?

25 A woman has a compulsion to put her hair in a certain position each time she lies down to go to sleep. But she she finds out, to her surprise, that when she does an exposure by lying down with her hair positioned differently, her SUD level is 2 on a scale of 10, and before long it goes down to 0. Which is she more likely to think?

A. I was really lucky on this one! It's easier than I thought it would be!

B. Wow, this is really a hard one. I'm going to have to really be tough.

26 Why do people advise working on compulsions starting with the easier ones first? Because each success that you have makes the next one easier. If you arrange the compulsions in the order of what you think the SUD level will be during exposure and ritual prevention, and start with the ones with the lower SUD levels, you will usually find that as you have successes with the easier ones, the SUD levels for the harder ones get less! This is because you gain more and more confidence with each success, that it's possible to get over a compulsion, and that it isn't as bad as you thought it would be.

In this section, the author

A. Explains a way of lowering SUD levels through relaxation,

B. Explains why it's usually good to start with the easier situations and work your way up?

27 We are going to start calling exposure and ritual prevention ERP.

The bad feeling that people anticipate or have during ERP is sometimes fear -- it's a feeling that something bad is going to happen, even though the person knows that the ritual doesn't really protect them against bad things. Sometimes the bad feeling is worry or tension or disgust or some other bad feeling. But if you have the skill of getting yourself into a relaxed state, usually relaxing helps you do ERP with a lower SUD level from the start and helps the SUD level go down more quickly.

What point does the author make in this section?

A. Relaxing during ERP often makes the ERP less unpleasant and more successful.

B. What you say to yourself, what your self-talk is, during the ERP, has a big effect on the SUD level?

28 There are many ways of relaxing. In one of them, you focus on relaxing your muscles, on making them less tense, more limp and loose. You can combine this with breathing in for five seconds and out for five seconds. As you breathe in, you get a group of muscles in mind -- for example the muscles of your head and face, or the muscles of your neck, your upper shoulders, etc. As you breathe out, you try to reduce any tension in those muscles, and to make them loose and relaxed. It's good to practice this for just a little time, often, when you're not doing ERP, and to see how successfully you can get yourself into a nice relaxed state. A couple of minutes of practice of this every day is a great thing to do.

What method of relaxing is the author describing?

A. Using a "mantra," which is a word that you repeat to yourself?

B. Breathing 5-seconds-in-and-5-out, getting a muscle group in mind as you breathe in, relaxing those muscles as you breathe out?

29 Another thing that makes ERP more pleasant is to try to make good choices about what you say to yourself, which is called your self-talk. Suppose that someone starts an ERP and is thinking, "Oh no, this is going to be so unpleasant, why did I ever agree to to this? I just can't stand the way I feel when I don't do the ritual!" That self-talk probably makes the ERP much more unpleasant. On the other hand, suppose the person thinks this: "If I can get used to this situation, that will make my life lots better! It may be tough, but if I'm able to tough it out, I will deserve to feel really good about myself! Every successful ERP that I do helps me to get to where compulsions don't bother me at all! Every second of ERP is something for me to celebrate!" This type of self-talk makes the ERP much more pleasant.

What's a summary of what this section says?

A. An ERP session where you do the exposure and don't let yourself do the ritual for a good length of time is successful, even if the SUD level doesn't go down close to zero.

B. If your self-talk focuses on what an accomplishment you're making and how celebration-worthy your efforts are, rather than how bad it is to have to do something unpleasant, that makes the experience much more pleasant.

30 Here's something very important, that many people don't realize. It's possible to make great progress by doing ERP in your fantasy, as well as by doing them in real life. These are called fantasy rehearsals of ERP.

Someone has some compulsions that get in the way of handwriting. If certain letters aren't done in a way that feels right, the person has to erase and do it over. For example, it doesn't feel good if the dot over an i isn't in just the right place. The person imagines that a miracle has happened. They imagine that they are just writing without worrying about how the letters are formed; they are thinking about what they are writing about; it feels liberated (or freed up) and relaxed and pleasant to do the writing without even getting the urge to do any rituals. This is called a "mastery" fantasy rehearsal -- the person is imagining that the compulsion is totally gone.

In this mastery fantasy rehearsal, the person imagined

A. Needing to be very tough and strong in order to do the ERP, but succeeding at it,

B. A miracle has happened so that the compulsion is gone, and there isn't even any need to be tough and strong, but just to enjoy the situation?

31 In a "coping" fantasy rehearsal, you imagine that you do have to be somewhat tough and strong to handle the ERP, but that you are able to do it. For example: "I'm writing, and I've decided to do ERP by just writing one without stopping to erase and do anything over. If I can accomplish this, it will be a really big deal! ... I'm writing, and I don't let myself erase, even though I have a really strong urge to. I tough it out and I find that soon the SUD level falls as I get used to this. Hooray, I used self-discipline!"

In this coping fantasy rehearsal, the person imagined

A. Having a non-zero SUD level during the ERP,

B. Having a zero SUD level during the ERP?

32 Which is better to do: mastery or coping fantasy rehearsals? The answer is that it's better to do both! It's good to do mastery rehearsals because this is what you want it to be like, eventually, to be in the situation. It's good to do coping rehearsals so that when you get around to doing ERP in real life, it doesn't surprise or upset you to find that you have to cope with a SUD level. Doing a lot of mastery rehearsals sometimes lowers the SUD levels to very low points before you even do real-life ERP, but it's good to be prepared in case it doesn't.

The author feels that between mastery and coping fantasy rehearsals,

A. Both have their functions, and it's worthwhile to practice both.

B. It's good to use only mastery fantasy rehearsals, because they often are pretty painless and it's desirable to feel as little pain as possible while getting rid of compulsions?

33 One great way of doing fantasy rehearsals is to write them out, or have someone help you write them or write them for you. Then you just read the fantasy rehearsals, ideally more than once each day.

Whenever you have successful ERPs and courage triumphs, if you can write down a description of this, and read it often, you are fantasy rehearsing what you've already done! But that helps you do other courage triumphs that are still on your to do list.

The main point of this section is that

A. A great way to do fantasy rehearsals is to write them out and read them daily.

B. The steps we've discussed are a lot of work, and it's good to remind yourself why the work is worthwhile.

34 Here's an important choice point: do you really want to get over compulsions, or do you just want to avoid discomfort? The things we've described are a lot of work. Hopefully, if we play our cards right, this work can be fulfilling, a reason to feel proud, a source of a real feeling of accomplishment. But it is work, and most of us tend to avoid work unless there's some payoff. For this reason, it's useful to write a list of the payoffs that come from getting over compulsions -- things like this:

1. I don't waste so much time.

2. I get to do much more pleasant things in the time I save by not doing compulsions.

3. I get to have the feeling of choosing what to do rather than having the feeling that I'm compelled to do things.

4. There are ways that I save other people some bother or inconvenience.

5. The total amount of discomfort and distress I feel is much less.

It's good to review such a list of payoffs often, perhaps daily.

What is the author advising you to do, often, in this section?

A. Relaxation practice and fantasy rehearsals?

B. Review of the list of payoffs from the work you do in reducing compulsions?

35 People often ask, will I be able to get rid of compulsions altogether? For most people that have had compulsions, urges to do rituals will "pop up" every now and then for a long time. But if one gets into the habit of doing ERP as soon as they are aware of a compulsion just beginning to form, one can "nip it in the bud," and compulsions get eliminated before they even get problematic. For this reason, I think there's reason to be very optimistic about the possibility of making compulsions not a problem any more. However, I think there's also reason to review ERP and all of the stuff we've talked about, so as to remain ready to jump on any new compulsion as soon as it begins to get started.

The author thinks that

A. Once you're successful, you can forget about compulsions for the rest of your life.

B. Once you're successful, you know how to nip in the bud any other compulsions that pop up during the rest of your life, as long as you don't forget it!

36 Even if you have such an unusually good memory that you can remember all this after hearing or read it one time, it's a good idea to read or hear this a good number of times. Why is that? Because we read or hear things not only to learn them for the first time, but to remind ourselves of what we already know. In addition, it's probably a good idea to get some repeated exposures to these ideas, and practice thinking about them, because for some people they themselves are trigger situations that may have a SUD level at first. Congratulations for going through them, either for the first time or for one more time!

The author gives, in this section, a couple of reasons why

A. It can be a good idea to go through this handout several times.

B. It's good to write out fantasy rehearsals in addition to making them up and imagining them.