Barrier 2 - Automatic Compulsions, ‘my mind just ruminates’

This is part of our key barriers to OCD recovery series. Barrier 1 - Using ERP for controlling obsessions.

Next time someone you care about says something hurtful, just stop thinking about it! Before you go to an important event give it no planning at all. When you have a moment of regret and a ‘shame attack’ about something you said, drop it immediately. When your attention is locked on a headache or other pain, let go of directing attention to it immediately. Just drop it! If only it was that easy!

 None of these challenges are particularly easy for anyone to do. Rare individuals can naturally do this more easily and remain calm and equanimous through life.  But most of us would struggle intensely. Our mind is pulled back to the salient issue, trying to solve it or monitor it, plan escape or check if it is still there. Over and over. Many therapists tell their clients just to stop ruminating and drop mental compulsions about their greatest fears. If we can’t stop thinking about what we are having for lunch, is it that simple for someone in the grips of OCD to stop ruminating?

I don’t believe it is and I don’t think it was for me when I was in the grips of OCD in the past. My mind would ruminate automatically almost all the time. My attention was drawn to an unpleasant sensation over and over. Part of my mind would monitor it without my volition. I could do this whilst simultaneously having a conversation. Many times, I would ‘come to’ from a dissociative/ruminative daze and realise I had been ruminating whilst driving or doing other activities without even knowing. We get good at task switching over time, so we can be doing mental compulsions whilst chatting and performing other complex tasks. This is much like when we drive a car and can drink a coffee, listen to music and have a conversation at the same time.

Many of my clients have had the same experience and have felt very invalidated when clinicians have told them just to drop it. Often, they have not shared this with the therapist due to power dynamics (wanting to be a ‘good client’) and their wish for therapy to work. I have had clients that read articles about ‘just stopping’ rumination and then experienced some of the worst OCD episodes of their lives. They were determinedly trying to do this, creating tension and struggle and ultimately increasing their mental compulsions.  They also ended up feeling shame and hopelessness that they are unable to ‘just drop it’ like they believed others could.

Other times, therapist advice may be ‘just stop ruminating’ and to use techniques like interrupting the rumination with ‘maybe-maybe not’ statements, agree with OCD in a humorous way, agree with the worst-case scenario, use scripts and loop tapes to interrupt the mental compulsions etc. This can help but for highly ruminative clients (like I was) it often adds more rumination, as the client monitors whether it is ‘working’. Or they ruminate as they try to decide which technique to use. Also, rumination may increase as their OCD brain responds to the tool with resistance, as it is still frightened of these uncertainties (it may elevate intensity, switch theme or details of uncertainty, question recovery methods etc). Additionally, with the intensity of intrusive thoughts you often don’t have time to do these interventions. There is no time as the mind maybe ‘pinging’ multiple intrusive thoughts over and over and the brain wants to start ruminating in an instance. It can all get very messy for the highly analytical client. We can doubt everything and every response. Just living can feel like a continuous trigger.

This difficulty with ‘just stopping’ ruminating is the bad news. But the good news is that we can train to do this. And for thousands of years humans have been training their attention, learning to drop discursive thoughts, to stand back and not react with judgement and rumination to their experience. Different meditation practices are found throughout all of human culture that train these skills. We don’t need to meditate to achieve this, but we can learn from those traditions to develop more effective therapy methods to achieve this end. Third wave cognitive behavioural therapy has learnt a lot from these approaches. Many skilled CBT/ERP clinicians integrate these ideas into their therapy process to help with mental compulsion cessation.

We don’t need to do formal mindfulness meditation to develop these skills - in fact it isn’t targeted enough to often help with OCD. But we can utilise the skills from mindfulness and practice them in exposure and response prevention work and whilst responding to OCD triggers throughout the day. Many clinicians have integrated ACT, DBT, mindfulness, metacognitive therapy and other skill-based tools with ERP, to help with this. I think it is an essential part of therapy in order to catch the insidious and automatic mental and physical compulsions that can be barriers to improving. We will explore another client example to highlight this process.

Meng was a highly introspective and analytical student. He was studying computer sciences at a prestigious university. He could not stop his mind looping on thoughts of freewill, meaning and life or death. At times he feared he was in a simulation. Other times he thought he was like a robot with no freewill, controlled by his evolved biology and the outside world. Sometimes these intrusive thoughts would come with intense panic and dread. Other times he would feel despair, low motivation, and a blunted painful sadness. He was becoming more and more isolated. He would spend hours researching these topics. He spent much of his day listening to Sam Harris and other philosophical and scientific minds talking about these topics on YouTube. Why were they not terrified like Meng? Why could they keep being highly productive in the face of these existential questions? He felt periods of depersonalisation and derealisation. The world around him looked unreal, like it was behind a thick pane of glass and his senses felt off. He couldn’t locate the feeling of himself and he would stare in the mirror feeling lost and unable to connect with the person looking back. 

Meng had tried antidepressants and at first, they had given him a little more motivation. But before long he felt his thoughts and feelings creeping back in and he felt more low mood and despair. At times, he would have passive suicidal thoughts. Sometimes these felt like they would offer relief from the constant pain. At other times they frightened him. 

Meng had discovered ERP in his online searching and he signed up with a CBT therapist. They talked about his life and the impact OCD was having on it. He told the therapist he couldn’t concentrate on anything except this topic, everything would lead him back to it. He would look at a tree and be acutely and painfully aware it would outlive him. He would notice every sensory glitch and think it was evidence of the simulation. Elderly people would trigger intense panic in him as they reflected his life slipping away. He kept thinking about meaning, freewill, isolation, death, consciousness and happiness. He felt he needed to solve these problems to move on with his life.

This therapist was deeply kind and this irritated Meng. He wanted someone to push him like he usually approached studying. The therapist started watching YouTube videos about simulations with him. Meng thought sceptically that this is what he did all day already. He felt he was just doing his OCD behaviour with the therapist so after a few months he discharged himself. Meng had been researching OCD recovery intensely and he found a therapist that talked a lot more about mental compulsions and rumination. Meng related to this. He signed up for therapy and felt this is what he was missing. The therapist walked him through the reasons he was ruminating on this topic and why he was invested in finding an answer. He did various exercises to show Meng what rumination was and how to stop it. Meng felt he could do these practices in the relative security of therapy. He didn’t feel triggered and he could direct his analytical mind onto the topic and then put it down. He was sceptical that he’d be able to do this in an OCD episode.

Sure, enough Meng watched a video on freewill on Tik Tok and it terrified him. The person was so convincing that it was an illusion and Meng felt waves of panic at the thought of not being in control of his life. He would oscillate between terror and despair. He tried with all his effort to stop ruminating but it was too difficult. Rumination would take over him and he was trying to stop it for hours. Or he would stop it, his mind would then wander onto how bad his life was (like he was single and lonely) and then he would loop back to freewill. He felt angry at his therapist. They had said he could stop it if he wanted to and just needed to try harder. Meng gave up on the sense that it was helping. He did want to stop ruminating. More than anything. He also didn’t know what to do when he stopped it, his mind just seemed to go onto other worries about his life. Added to this, at times he wasn’t even aware he was doing it. He was in a spaced-out daze, ruminating about these topics without even noticing. He’d managed to stop reading about them and watching videos, but how could he stop thinking about it? It was automatic.

He told his therapist. They seemed understanding but returned to the idea that he wasn’t committed to giving it up. They said it didn’t matter what he did after he stopped ruminating. But he had to want to do it. Meng was seething inside. He said he’d try again but, in his mind, he knew he needed to try something else.

Can we really just stop thinking about an argument with a family member. When you are feeling anxiety before a challenge can you really prevent yourself from checking how you feel. Imagine if you have had a severe illness like a heart attack, could you stop monitoring and checking your symptoms. Can we stop running through checklists during an important work period. Can we just stop thinking about someone we fell in love with, a shame memory, our child when they are late home? It is really difficult to stop analytical thinking. Stopping ruminating is not just a simple choice. It is a skill we need to master over time. If it was easy, people would go to a meditation class and on day one, they would learn to drop rumination and focus on their breath and be masters at it. This never happens. It takes months to see improvement.

After many years of doing mental compulsions, they become automatic. Different people have different degrees and qualities of internal self-talk. Clear and obvious, subtle and illusive. It’s the same as if you have run your to do list through your mind for years, your mind will do that automatically. If you have rehearsed arguments, remembered shameful memories etc the same will happen.

The automaticity is like the experience of driving down the road and not remembering the journey, reading sentences of book and not taking them in etc. Our brains like to put processes on auto-pilot to free up resources for other tasks and threats. Some people have more and more automatic inner monologues with varying levels of clarity of what is happening in their head. Some people only have images, felt sense and the compulsions are about their attention - monitoring and checking. This is equally difficult to just drop without training.

For some people, yes, dropping rumination is fairly easy. For many of us (including myself) it was not that easy. Often OCD therapists are smart logical people with precise minds, it may be easier to catch rumination and let it go with this type of mind. Some people can do this naturally well and this may relate to their innate brain structures (probably a strong prefrontal cortex and less reactive limbic system). But for many of us it’s not as simple as this. When I was struggling for hours a day, I would not even notice rumination and it would take a big spike of anxiety, doubt or despair to be aware it was happening.  

Rumination is part of the default mode network (DMN) of the brain, which is highly active in everyone at rest. Matt Lieberman’s work on the DMN shows that the DMN is often a self-referential loop with a social and threat focus. Research on the DMN shows that when people stop trying to solve a maths problem, within a few seconds people start to ruminate about their life and often difficulties in social connection.  That means we are often ruminating about where we position in a group, what issues we are experiencing in our social networks etc. So, if we stop ruminating about OCD we will likely start to ruminate about other distressing topics. It should be noted the DMN can also be a loop related to creativity so it is not always difficult and can be wonderful. The DMN is inhibited by the task orientating network. That means focusing on actions and the present moment start to inhibit the activity of the DMN.

 Intrusive thoughts are different. We can’t do anything to inhibit them. But we can learn to step back and allow them to come and go without reacting. When we are very skilled at this, we don’t even need to pay them any attention, through practice we can stay engaged in what we value and let intrusive thoughts come and go in the background.

Everyone benefits from training attention. That’s why athletes, frontline responders, the military, politicians, Tech CEO’s etc are all utilising mindfulness to train attention and help with rumination and worry. Scientists estimate that 40% of what we do on a daily basis is habitual, including many of our habitual thought loops. It takes deliberate training to shift this, just like a physical habit needs practice and determination to develop. Other automatic types of rumination can include depressive rumination, life worries, distracted mind wandering, self-criticism, social comparison and more. ACT skills help to cope with these problematic loops along with mental compulsions. This is where defusion and focusing on valued actions/task focused attention is so useful.

For some clients it even takes a long time to be able to observe and step back from the thoughts and it can be more automatic. This can be exacerbated by common comorbidities such as the combination of OCD with ADHD, ASD, trauma, addictions, major depression etc. I find the skills in this article useful in working trans-diagnostically across these difficulties.

Additionally, there is an idea being circulated that if we control rumination, we will eliminate anxiety. I would say I have not seen any convincing research that says dropping rumination will eliminate anxiety. Our brain has many centres implicated in anxiety and different neural pathways. Leaders in the field of neuroscience will say we know relatively very little about anxiety and how to reduce it. This promise of control over anxiety is highly seductive to anyone who has experienced an anxiety disorder. Trying to find tools that would remove anxiety was what drove me for decades. If any research is available that confirms elimination of anxiety by cessation of rumination, then I would be interested to see this (although I am highly sceptical that this is the case and I think it is a problematic message that reenforces avoidance).

In my mind the best thing we can do is learn to be comfortable in anxiety and not make it our goal to remove it. If we try to remove it, we will get paradoxical effects of feeling more anxiety as our threat system tracks for the presence of anxiety as a danger. A paradoxical increase of anxiety ensues, as anxiety triggers anxiety like microphone feedback, or like attempts to try hard to sleep keeps us awake. Alongside defusion skills, we need the ability to make room for physical anxiety. The next article will focus more on intense feelings.

Antidote – training to catch automatic compulsions

Meng reached out to me and we started therapy sessions soon after. Meng appreciated that I validated his experience that rumination is not always easy to stop. That it can become automatic and conditioned over many years. People vary in how active their minds are and the nature of their inner monologues. I described that we would use skills to train to let go of rumination and to mindfully step back and acknowledge when it was automatic. He liked the idea that we would choose actions he valued to engage in alongside defusion.

We also identified that he was being very harsh and commanding to himself. At first Meng found it hard to see the cost of this and he was worried he would lose his academic edge without being punitive and demanding on himself. We discussed that compassion could still be correcting, instructional and motivating voice. Just that it was done with warmth and support, like a good coach. We also looked at the cost of this inner critic and how in his current state he could barely study anyway, and so it was time to try something different. Meng agreed to try to cultivate this perspective and he found it increasingly helpful over time. We uncovered that his family were harsh and demanding and this was all he had ever known. His school had been the same.

Meng practiced the defusion skills, we worked a lot of the ‘dipping in and out of the stream’ practice and over time he felt that he could at least detach from the rumination a little more. At times he could let it go, at other times he would feel some distance from it. We started practicing exposure to existential videos and reading.  We would pause every so often and run through the defusion and emotional acceptance skills. Slowing things down, Meng was able to start to let go of mental compulsions more and more. We looked in detail how he was applying this in life, how his mind resisted this process. We set clear goals to train this skill during more intense periods of activation.

We identified that Meng was quite isolated and lonely and so made goals to reconnect with previous interests. He re-joined a dungeon and dragons’ group and had to fight 2 battles (one battle using his skills and the other in the game). He learnt to ‘surf the urge’ to ruminate on his intrusive thoughts, as he focused on the game and his friends. Meng also restarted playing badminton and limited the time he played on video games to an hour a day. He didn’t avoid existential content but he also didn’t spend hours researching and listening to it. He was engaged in his studies again and started to explore online dating.

Meng couldn’t ‘just stop ruminating’. He was incredibly smart and knew exactly that it was bad for him. He’d even used maths formulas to calculate the probability that he could answer these existential questions – he found the odds were not in his favour. Yet he could not just stop. He had to improve his ability to step back and observe his intrusive thoughts to learn to drop the active mental compulsions. He needed to learn to refocus on things that he valued, as his attentional system was less under his control than before the OCD episode. This process took a lot of training and he had some waves of feeling more able to do this then he would slip back into rumination. His recovery process was like a rollercoaster at times, but each setback taught him something. Meng noticed if he was diligent in practicing his skills then it got easier, this motivated him. We finished therapy and Meng said that he no longer was stuck in rumination and analysis and he felt much more engaged in his life. He still got existential intrusive thoughts at times, but he was able to step back from them and not engage in rumination anymore. He felt kinder to himself and his life was more balanced in terms of the way he was spending his time. He knows what to practice if he finds himself struggling with mental compulsions in the future.

Some of the key skills that were helpful for Meng and also for clients struggling with these difficulties:

·      Training and practice – Nothing beats daily practice. Training skills, targeted exposure and in the moment responses to triggers. One of the key ACT skills is cognitive defusion, learning to step back and observe thoughts without reaction, choosing where to allocate focus and ultimately to allow intrusive thoughts to come and go in the background without compulsions. The ability to engage in the present moment and valued actions supports defusion. Check out my OCD skills playlist for ways to train these skills methodically. Our precision and clarity of observing skills and sustained attention skills are not a one-time thing we learn. They are a skill that deepen over time through practice. Dropping anchor (later putting emphasis on only the A and E stages), defusion practices, dipping in and out of stream, are all good practices to work on this. ACT is one way to train these skills, but using other mindfulness approaches like the mindfulness training in CFT, MBCT and DBT, or metacognitive therapy, or ERP that emphasises these principles are other ways to train these skills. I like ACT because it has the most simplicity and clarity about the concept of acceptance and engagement in values-based behaviour. Daily practice will help the most and I recommend a minimum of 10 minutes but if you are struggling with OCD, then building up to 1-2hrs (which can be broken into chunks or combined with other daily habits throughout the day). This playlist walks through a practice sequence.

·      Notice and name, notice refocus, allow and sustain engagement – There are lots of varied defusion techniques in ACT to build the skill, but I like to keep it as simple as possible. This can be 3 approaches (1) noticing the intrusive thoughts and refocusing on valued actions (notice and refocus) (2) noticing the intrusive thoughts and using a simple silent mental label like ‘worry’ or ‘doubt’ or ‘judgement’ and refocusing on valued actions (notice, name and refocus) (3) ultimately building up to allowing the intrusive thoughts to be there and engaging in valued actions (allow and engage). This is not mindful ruminating; these tools are training wheels to help you learn to step back and detach from the intrusive thoughts (and not respond with mental compulsions as per step 3). Only when you can step back and not be absorbed in thoughts, can you start to catch the mental compulsions more easily and let them go. I don’t think ERP can be as helpful until we have trained this ability as it can increase mental compulsions without us even realising. Ultimately, we want to get to the defused stance of (3) ‘allow and engage’. But if we start to struggle and get distracted by the obsessions and compulsions, then we can go back to (1) ‘notice and refocus’ or (2) ‘notice & name and refocus’. See this practice sequence to learn more about this training approach. Also using these steps within dipping in and out of the stream builds this skill more strongly.

·      Intention and reflection – this involves setting ‘implementation intentions’ each day to engage the skills of defusion, acceptance, present moment attention. We set goals around areas of life we know are going to challenge us, we set goals for triggers where we want to remember to come back to these skills. We repeat this a few times in the morning or before the activity so this sinks into our mind and is more likely to be a ‘cued behaviour’ that is activated by the situations and contexts. So subconsciously you are starting to catch a behaviour and then triggering the implementing of the skill. This is similar to how you might cue the behaviour of walking out of the house together with making sure you have your keys. Or another example, you say to yourself I want to wake up at 5am for my flight and you wake up the next day at 4.59am.

·      Train focused attention – practicing sustaining attention on a simple object of attention through ACT practices or other approaches to mindfulness and meditation is helpful. This is as much about ‘refocusing’ or noticing a wandering mind and bringing it back. You can also train this through intellectual, physical practices or creative activities.  This could include reading more complex material, listening to people, studying, mindful activities like walking in nature, mindful movement like yoga, setting a goal to not ‘double screen’ and sustain your attention on a movie, listening to music without mind wandering (refocusing on the music), sustaining your attention on problem solving/methodical thinking etc. You train task focused attention and this can include task focused thinking, where thinking supports the action, we are engaging in (like strategizing, motivating, instructing, savouring self-talk etc). Set timers on single tasks and notice and refocus your attention over and over as it wanders. Choose a range of highly stimulating to more monotonous and boring tasks to train your attention (it’s harder with the monotonous tasks). Use both movement, focusing on senses and thinking based attentional tasks. The best is to train attention across multiple domains. Most people feel in their lives that they are distracted and can see the value of training attention. There is value for everyone in training our attentional muscles.

·      Emphasise defusion if you can’t let go of mental compulsion – sometimes people cannot let go of their automatic mental compulsions in the beginning. If the thought loops are on automatic then training in defusion is a great step to start to learn to let go of mental compulsions. If you can’t easily drop a mental compulsion then practice the defusion skills. My experience was that overtime and through practicing this, it became a lot easier to notice rumination and to let it go. This is not mindful rumination; it is a training tool to increase the ability to drop rumination. By looking closely with acceptance at our thoughts and refocusing on present moment actions we value (not as distraction to push thoughts away but as acceptance and a choice to engage in things we value) you start to see what you are ‘subvocalising/speaking the rumination’ in your head, or directing your attention to check and monitor. This is just like in a mindfulness practice, that you learn to catch when rumination pulls you away from an anchor like the breath, to let the rumination go and refocus on the anchor. No one enters a mindfulness class and can do this without training. It is the same with rumination. It takes practice.

·      Notice and step back as soon as you can - no matter what point you catch yourself in compulsions. You can implement these skills mid compulsion as you realise you are ruminating and then defusion will help to catch this process more effortlessly and prevent compulsion. You can do this before, during or after a sequence of compulsion. Catch this process with compassion, see it as learning a skill (not something you should be ‘perfect’ at) and train it. This is far less ‘victim blaming’ than telling people just stop ruminating and if they can’t saying ‘you don’t want to’. This also applies for physical compulsions. In my experience physical compulsions are often proceeded by mental compulsions like planning, worrying, commanding, helplessness thought loops. So, we can practice catching the mental compulsions along with the physical compulsions as we improve our skills.

These skills take time to build up and gain more acuity through practice. It’s like there are ‘micro moment’ sequences between trigger, obsession, judgment to subtle mental compulsions to gross (obvious) mental compulsions. It is the same with attentional compulsions like monitoring or checking feelings. Through training you learn to catch this sequence earlier and to let go of more of the subtle compulsions and resistance to the ‘meaningless noise’ of the intrusive thoughts.

You could discuss some of these ideas with your therapist. You could take the OCD skills playlist and start to practice the sequence of skills to see if it adds to your recovery toolbox. If you are struggling with mental compulsions then reach out and find a therapist that gets them.

These skills are useful for all of life and can be applied to everyday worries, depressive rumination, self-criticism, shame and guilt and any painful thought process. Give it a try and let us know how you get on.