DB 2 Psyc 620

Exposure Therapy for Obsessive-Compulsive Disorder

1: Session Opens

0 seconds DR. MARTIN ANTONY

[00:00] DR. MARTIN ANTONYHello. CLIENT: Hello. DR. MARTIN ANTONY: I want to thank you for agreeing to do this. What I’d like to do today is begin by just asking you some questions, to very quickly just get an overview of the kinds of difficulties that you’ve been having and the triggers for the anxiety and the types of things that you do to get rid of it and then probably spend the rest of the time talking about strategies that you can use to overcome the problem or at least reduce it’s impact on your life. Is there anything else that you’d would like to make sure that we cover today?

34 seconds CLIENT

[00:34] CLIENTNo, not really. DR. MARTIN ANTONY: No? Okay. Well, if at any point anything comes up,

39 seconds DR. MARTIN ANTONY

[00:39] DR. MARTIN ANTONYjust let me know and we can make sure that we deal with that. So, the focus today will be primarily on obsessive-compulsive kinds of behaviors. I’m wondering, to start, if you can just provide me with an overview of the kinds of difficulties that you’ve been having.

2: Presenting Concerns

54 seconds CLIENT

[00:54] CLIENTWhat I do is I take letters, I’ll pick a word and I even out the word and if it’s numbers I read out the number or I’ll spell the number out and try to even it out and I wont stop until it’s done, it’s completely even. DR. MARTIN ANTONY: Okay, so if you see,

1 minute 14 seconds DR. MARTIN ANTONY

[01:14] DR. MARTIN ANTONYto come back to numbers, if you see the number seven on somebody’s house or something, what you do with that? CLIENT: It depends. Sometimes I’ll

1 minute 24 seconds CLIENT

[01:24] CLIENTdo a plus one to equal eight and then you know, the eight four and four, then I’ll break it down, okay four and four is, four two and two, then one and one, then half, a half then I’ll go down or I’ll take the number seven and convert it into how you spell it and I’ll try to even that out. DR. MARTIN ANTONY: So how would you do that, so you have S-E-V-E-N?

1 minute 49 seconds CLIENT

[01:49] CLIENTS-E-V-E-N, so I’ll do S-E-V then I’ll put that out and I’ll put E and S to make seven and then sometimes I’ll go even further and add a number to that and keep doing it over and over again. DR. MARTIN ANTONY: So can you give me example of how you’d add number to that?

2 minutes 4 seconds CLIENT

[02:04] CLIENTI’ll do like a 7-8. S-E-V-E-N on one side then E-I-G-H-T on the other and that’s even. DR. MARTIN ANTONY: So, it has to have the same number of letters on both sides

2 minutes 14 seconds DR. MARTIN ANTONY

[02:14] DR. MARTIN ANTONYof the letter. CLIENT: Yeah, it’s all done in my mind, I don’t do, I don’t write

2 minutes 19 seconds CLIENT

[02:19] CLIENTanything down. DR. MARTIN ANTONY: You don’t say anything out loud. CLIENT: No. DR. MARTIN ANTONY: Okay. If you are writing and you

2 minutes 24 seconds DR. MARTIN ANTONY

[02:24] DR. MARTIN ANTONYcome across one of these letters, will you still do it in your mind or will you?

2 minutes 29 seconds CLIENT

[02:29] CLIENTSometimes, but it’s may only words I read. DR. MARTIN ANTONY: Okay, it’s mostly stuff that you’re reading. CLIENT: Yeah. DR. MARTIN ANTONY: Okay. If you hear

2 minutes 34 seconds DR. MARTIN ANTONY

[02:34] DR. MARTIN ANTONYsomebody say a word, will that ever trigger things or does it have to be in writing usually? CLIENT: More in writing but sometimes when, if I know how to spell, like

2 minutes 44 seconds CLIENT

[02:44] CLIENTbefore, I then saw one of my professors, so I go, and I thought about his name, so then I did his name in my head. DR. MARTIN ANTONY: Okay and how,

2 minutes 54 seconds DR. MARTIN ANTONY

[02:54] DR. MARTIN ANTONYyou said you’d divide you know, you keep going backwards, so you divide two into two 1’s and then the 1’s into two halves and how would you know when to stop?

3 minutes 4 seconds CLIENT

[03:04] CLIENTIf I can’t do it anymore or if I find something else to do or my mind just might get distracted and go back on track. DR. MARTIN ANTONY: Okay, otherwise you just keep going as long as you can.

3 minutes 14 seconds CLIENT

[03:14] CLIENTYeah. DR. MARTIN ANTONY: Okay, and so part of it is just taking these words and numbers and

3 minutes 19 seconds DR. MARTIN ANTONY

[03:19] DR. MARTIN ANTONYsplitting them up essentially and then splitting up those and splitting up those over and over and over again. Do you do any another counting?

3 minutes 29 seconds CLIENT

[03:29] CLIENTAs far as, like as far as an even amount of something or, not really, no.

3 minutes 39 seconds DR. MARTIN ANTONY

[03:39] DR. MARTIN ANTONYNo? I’ve seen some people, for example, if they look up their ceiling tiles, they have to start counting them or something like that, nothing like that. CLIENT: No, not like that. It’s mainly numbers and letters.

3 minutes 49 seconds DR. MARTIN ANTONY

[03:49] DR. MARTIN ANTONYOkay, and what kinds of situations bring on this urge to do that?

3 minutes 54 seconds CLIENT

[03:54] CLIENTAnything anxiety provoking. DR. MARTIN ANTONY: So can you give me an example?

3 minutes 59 seconds CLIENT

[03:59] CLIENTWhen I have a paper to write, I’ll do it then. If I’m stressed out at work, I do it then or any situation with heightened anxiety, I’ll do it. I’m in the car, I’ll do it till I can sleep. All the time. That’s the worse one. DR. MARTIN ANTONY: Is there anything you avoid because

4 minutes 19 seconds DR. MARTIN ANTONY

[04:19] DR. MARTIN ANTONYit may trigger the need to do this? You would avoid driving, for example? CLIENT: No, I just

4 minutes 24 seconds CLIENT

[04:24] CLIENTgo about my regular day. The biggest problem now is when I read books. DR. MARTIN ANTONY: Yeah. CLIENT: Sometimes I do it when I’m reading a book and that makes it hard to read the book, so I can’t read every word.

4 minutes 39 seconds DR. MARTIN ANTONY

[04:39] DR. MARTIN ANTONYRight. CLIENT: I have to skim a lot and I have to pick up key words and just I have to speed read

4 minutes 44 seconds CLIENT

[04:44] CLIENTor I would spend a lot of my time doing that and it’s very hard for me to understand when I’m...(crosstalk)

4 minutes 49 seconds DR. MARTIN ANTONY

[04:49] DR. MARTIN ANTONYDo you mind if I just take a few notes of the things I want to come back to? CLIENT: No I don’t. DR. MARTIN ANTONY: Okay. So when you’re reading, so do you end up missing a lot of, are you a student right now, so do end up...(crosstalk)

4 minutes 59 seconds CLIENT

[04:59] CLIENTYeah. DR. MARTIN ANTONY: So do you end up missing a lot of detail when you’re studying. CLIENT: Sometimes, yes. DR. MARTIN ANTONY: Yeah. CLIENT: So, I do less during the rest of that paper. I refer to lecture notes a lot, I really don’t do any reading except for my classes, I mainly go back and read or look at my notes. It’s hard for me just to read a book. DR. MARTIN ANTONY: So are your grade affected? Or if the class have been...(crosstalk) CLIENT: I’ve done pretty well. I think I could do better, but lots of people, I think, would be happy with the grades that I get if it was them, but.

5 minutes 29 seconds DR. MARTIN ANTONY

[05:29] DR. MARTIN ANTONYSo do you avoid taking classes where you really would have to be reading the book closely to do better? CLIENT: If I could, I would, but I’m at the point

5 minutes 39 seconds CLIENT

[05:39] CLIENTwhere I want my degree so, I need to take what I have to take, so yeah.

5 minutes 44 seconds DR. MARTIN ANTONY

[05:44] DR. MARTIN ANTONYOkay, so but you are able to do well just through with lecture notes and with things like that. Okay. So this doesn’t happen with your lecture notes? CLIENT: No, it’s mainly single

5 minutes 54 seconds CLIENT

[05:54] CLIENTletters but when I’m trying to read a book, I never like to read. So when I read, it causes a lot of anxiety because I really have to focus on it and I just do it sometimes when I read, certain words in there to keep my mind off the reading and do something else.

6 minutes 9 seconds DR. MARTIN ANTONY

[06:09] DR. MARTIN ANTONYOkay, so the problem with reading is partly this but it’s also partly that you just finding reading difficult anyway, okay.

6 minutes 14 seconds CLIENT

[06:14] CLIENTYeah. I’ve never liked it. DR. MARTIN ANTONY: Okay,

6 minutes 19 seconds DR. MARTIN ANTONY

[06:19] DR. MARTIN ANTONYlet me ask you about a few other obsessive-compulsive kinds of behaviors that people often engage in. Any difficulties around contamination, a fear of germs or cleaning fluids, or...(crosstalk). CLIENT: No. DR. MARTIN ANTONY: No? any need to wash or clean things or have things neat?

6 minutes 39 seconds CLIENT

[06:39] CLIENTDepends. When I do have to wash my hands a lot but I can tell you that I taught pre-school for 5 years...(crosstalk) DR. MARTIN ANTONY: I’d do it. CLIENT: And killing germs all the time. I think attribute that to that but cleaning when I clean, I have to clean a very specific way. DR. MARTIN ANTONY: Let me ask about the washing for a moment. How many times a day do you wash?

7 minutes 4 seconds CLIENT

[07:04] CLIENTReally just when I come in and out from outside, maybe about...(crosstalk) DR. MARTIN ANTONY: 5 or 10 times or...(crosstalk) CLIENT: Yeah maybe and then every time that I use the restroom, of course. I’m married, so I have my husband around, so whenever mainly if I have to shut the bedroom door or like the bathrooms and that, I don’t touch the handle, I have to have a paper towel or I have to use my shirt as...(crosstalk) DR. MARTIN ANTONY: In your own home as well?

7 minutes 34 seconds CLIENT

[07:34] CLIENTA lot of times I do this because I don’t think my husband washes his hand all the time, so. He doesn’t care about the germs, but I do. DR. MARTIN ANTONY: And are they quick washes

7 minutes 44 seconds DR. MARTIN ANTONY

[07:44] DR. MARTIN ANTONYwhen you wash your hand? Like under a minute. CLIENT: Yeah, probably yeah.

7 minutes 49 seconds DR. MARTIN ANTONY

[07:49] DR. MARTIN ANTONYOkay. Would other people see them as quick or you think? CLIENT: I think other people

7 minutes 54 seconds CLIENT

[07:54] CLIENTwould see them as longer than they usually do. DR. MARTIN ANTONY: So they are longer than average, but still not...(crosstalk)

7 minutes 59 seconds CLIENT

[07:59] CLIENTIt’s basically I wash the way you’re supposed to wash and I do the alphabet or something in my head, but that’s what I learnt from teaching the kids to wash their hands properly.

8 minutes 9 seconds DR. MARTIN ANTONY

[08:09] DR. MARTIN ANTONYAnd tell me about the cleaning. CLIENT: I have to make a list, I have to go over to my room,

8 minutes 14 seconds CLIENT

[08:14] CLIENTI have to clean my house. Generally, I do basement, what I’ll do, if I plan to clean at night, I currently substitute, so I’ll take a little bit of time on my break or something and make up my cleaning list. DR. MARTIN ANTONY: Okay.

8 minutes 29 seconds CLIENT

[08:29] CLIENTI will list the room, then number 1 through whatever of what I’m going to clean in the order, and I have to go in that order. DR. MARTIN ANTONY: Okay. CLIENT: And I get very specific.

8 minutes 39 seconds DR. MARTIN ANTONY

[08:39] DR. MARTIN ANTONYWhat would happen if you didn’t go in that order?

8 minutes 44 seconds CLIENT

[08:44] CLIENTIt doesn’t happen. It must go in that order.

8 minutes 49 seconds DR. MARTIN ANTONY

[08:49] DR. MARTIN ANTONYWould it be overwhelming if you didn’t, would it be very anxiety provoking?

8 minutes 54 seconds CLIENT

[08:54] CLIENTYeah it would, I won’t even let my husband clean the house. DR. MARTIN ANTONY: Okay. CLIENT: You know, he doesn’t clean because it has to be done the way I like it. DR. ANTONY: Okay. And it’s not even so much about getting things a certain level of cleanliness;

9 minutes 4 seconds DR. MARTIN ANTONY

[09:04] DR. MARTIN ANTONYit’s about doing in the right order and in the right, according to certain rules or routines. Are there other things that you do in a certain order like getting dressed in the morning or...(crosstalk) CLIENT: I have strict rituals in the morning.

9 minutes 14 seconds DR. MARTIN ANTONY

[09:14] DR. MARTIN ANTONYYeah. Can you tell me a bit about those?

9 minutes 19 seconds CLIENT

[09:19] CLIENTWell, we have two dogs. He leave for work like 5 clock in the morning. I snooze two to three times, I let the dogs outside, I use the restroom or get, you know, breakfast or I do whatever, then I feed the dogs and the little one has to eat when I’m around, so I put her bowl down in the bathroom while I’m showering, she has to eat while I’m in the shower and then I go out, I basically get up maybe half hour before I have to leave and I do this all within a half hour, I eat everything within half hour. DR. ANTONY: A lot of people do things in a certain order

9 minutes 54 seconds DR. MARTIN ANTONY

[09:54] DR. MARTIN ANTONYbut if they didn’t do in that order, it’d be okay. In your case...(crosstalk)

9 minutes 59 seconds CLIENT

[09:59] CLIENTNo. I don’t like to do without order. DR. ANTONY: So it really, really has to be done in that way. CLIENT: Yeah. DR. ANTONY: Okay.

10 minutes 4 seconds CLIENT

[10:04] CLIENTI just prefer it that way. D: Have you had times where you couldn’t because something happened, the phone rang or...(crosstalk) CLIENT: Yeah and if I wake up and I don’t have time to take a shower, I go nuts the entire day because that’s the one thing I have to fit; I would be late to work but I have to shower in the morning.

10 minutes 19 seconds DR. MARTIN ANTONY

[10:19] DR. MARTIN ANTONYOkay. How long dos your showers take? Are they quick showers or...(crosstalk)

10 minutes 24 seconds CLIENT

[10:24] CLIENT5-10 minutes, not long at all. I don’t have much time.

10 minutes 29 seconds DR. MARTIN ANTONY

[10:29] DR. MARTIN ANTONYAre there things that you have to check over and over again, to make sure you’ve done them a certain way or once you’ve done something, are you usually okay with it?. CLIENT: The only things that I’m a little paranoid about is,

10 minutes 39 seconds CLIENT

[10:39] CLIENTit’s the oven. I always make sure I turned the oven off. DR. ANTONY: Just once or would you go back and check a few times?

10 minutes 44 seconds CLIENT

[10:44] CLIENTNo just once. DR. ANTONY: Okay. CLIENT: I just, before we leave the house or something, I make sure I turned the oven off or something like that.

10 minutes 49 seconds DR. MARTIN ANTONY

[10:49] DR. MARTIN ANTONYWhat about having to repeat some action, other action over and over again, other than what we talked about with the words. Re-doing things?

10 minutes 59 seconds CLIENT

[10:59] CLIENTNot so much. DR. ANTONY: Not so much. A bit aggressive

11 minutes 4 seconds DR. MARTIN ANTONY

[11:04] DR. MARTIN ANTONYor sexual or religious thoughts that are frightening to you, sort of thoughts that pop into your head that are really disturbing. No? CLIENT: No, not really. DR. ANTONY: Okay. What about having to do things symmetrically, again not including what you mentioned earlier with words, having to have things even, not even numbers but sort of equal distance or...(crosstalk)

11 minutes 24 seconds CLIENT

[11:24] CLIENTMy dishes in my cabinet, when they have to be, I have two or three sets of different types of cups you just pick up and I usually like to keep the same cups in a row and it just looks nice.

11 minutes 39 seconds DR. MARTIN ANTONY

[11:39] DR. MARTIN ANTONYOkay, so you prefer it that way, but it wouldn’t bother you if...(crosstalk)

11 minutes 44 seconds CLIENT

[11:44] CLIENTYeah. Not really, if I’m in a hurry, it doesn’t drive me nuts. DR. ANTONY: Its fine, okay. Would people describe you as a perfectionist?

11 minutes 49 seconds CLIENT

[11:49] CLIENTNo. DR. ANTONY: No? CLIENT: No, I don’t think so. DR. ANTONY: Okay, so coming back

11 minutes 54 seconds DR. MARTIN ANTONY

[11:54] DR. MARTIN ANTONYto these things that you’ve mentioned, so the reading issues, the cleaning things in a certain way, or morning rituals, how much extra time do you think these things take you on an average day compared to what if this wasn’t a problem for you?

12 minutes 9 seconds CLIENT

[12:09] CLIENTProbably a few hours. DR. ANTONY: A few hours a day. CLIENT: Yeah. DR. ANTONY: Okay. Do you ever try not to do

12 minutes 14 seconds DR. MARTIN ANTONY

[12:14] DR. MARTIN ANTONYany of these rituals or...(crosstalk) CLIENT: Yeah. DR. ANTONY: Yeah? And were you successful or...(crosstalk)

12 minutes 19 seconds CLIENT

[12:19] CLIENTDepends on the day. Sometimes I do, like today I was driving here, I was getting kind of anxiety because I was running late, the weather is getting bad outside and then I look up and I have, one of the schools I saw that had letters on there, I started doing like, no, no, I can’t tell myself not do it. Eventually, I just did it and got it out of my head and I was done. DR. ANTONY: Okay. CLIENT: So sometimes it takes longer for me to fight it than just let it.

12 minutes 44 seconds DR. MARTIN ANTONY

[12:44] DR. MARTIN ANTONYAnd if these things, so there are three things that you mentioned are things you do with letters and numbers, cleaning and the morning rituals. Of those three things, which of them is the biggest issue for you right now? CLIENT: The...(crosstalk). DR. ANTONY: It’s the counting? CLIENT: Yeah the books and yeah.

12 minutes 59 seconds DR. MARTIN ANTONY

[12:59] DR. MARTIN ANTONYOkay. CLIENT: The letters. DR. ANTONY: So we’ll make sure that we talk about that and I also would like to talk a little bit about the other issues as well, if you’re okay for that, we’ll see how the time goes. So let’s turn our attention then to the counting. I’m not even sure, it’s not really counting. I guess, in a way it’s dividing...(crosstalk) CLIENT: Yeah. DR. ANTONY: It’s doing things with numbers and words in your head. Are there any beliefs that go along with that about what might happen if you didn’t do that? CLIENT: No, not

13 minutes 34 seconds CLIENT

[13:34] CLIENTreally, no. DR. ANTONY: Okay, so it like a thought that if you don’t that then something will happen.

13 minutes 39 seconds CLIENT

[13:39] CLIENTI’d prefer to do without it...(crosstalk) DR. ANTONY: Okay CLIENT: Then, If I can imagine life without it, it would be nice. DR. ANTONY: Okay, but there’s no, I mean, some people do things because they’re afraid if they don’t do that thing,

13 minutes 49 seconds DR. MARTIN ANTONY

[13:49] DR. MARTIN ANTONYthen something bad will happen. It’s not that so much for you? CLIENT: No, I don’t think.

13 minutes 54 seconds DR. MARTIN ANTONY

[13:54] DR. MARTIN ANTONYSo, if you don’t do it, then what does it feel like?

13 minutes 59 seconds CLIENT

[13:59] CLIENTI always do it...(crosstalk) DR. ANTONY: If you’d ever delay it a little bit, just so to

14 minutes 4 seconds DR. MARTIN ANTONY

[14:04] DR. MARTIN ANTONYsee if you can do that? CLIENT: Yeah and...(crosstalk) DR. ANTONY: Just feels bad or...(crosstalk)

14 minutes 9 seconds CLIENT

[14:09] CLIENTYeah it’s just weird, it’s weird if I don’t do it but...(crosstalk) DR. MARTIN ANTONY: You find the urge to do it kind of builds

14 minutes 14 seconds DR. MARTIN ANTONY

[14:14] DR. MARTIN ANTONYand it becomes overwhelming? CLIENT: Yeah. Like more. DR. MARTIN ANTONY: Okay, is it a feeling of anxiety or?

14 minutes 19 seconds CLIENT

[14:19] CLIENTUh-huh. DR. MARTIN ANTONY: Yeah, okay. So, I know you’ve

14 minutes 24 seconds DR. MARTIN ANTONY

[14:24] DR. MARTIN ANTONYbrought in a couple of books actually that you mentioned were particularly difficult, they’re children’s books that have few words on a page, maybe one or two words or whatever, which I guess when a word is isolated like that, the urge to do it is much stronger, so we’ll look at those in a moment. What I’d like to do is just for a moment, just to talk to you a bit about what kinds of strategies you might use to deal with these kinds of things and when I asked you first, have you ever had a fear in your life that you’ve managed to get over somehow, maybe when you were a kid having a fear of the dark or?

14 minutes 59 seconds CLIENT

[14:59] CLIENTYeah, fear I had fear of the dark and my main fear is I hate to fly.

15 minutes 4 seconds DR. MARTIN ANTONY

[15:04] DR. MARTIN ANTONYOkay. CLIENT: Very high. I hate flying. DR. MARTIN ANTONY: And that fear is still there, you still have that fear?

15 minutes 9 seconds CLIENT

[15:09] CLIENTYou know, it’s little better because when we’re married we wanted to Jamaica to get married and the hotel we stayed at the resort was right next to the airport, so all day long, planes were flying over your head and that helped a lot with, you know, with anxiety of flying. DR. MARTIN ANTONY: Why you think that helped?

15 minutes 29 seconds CLIENT

[15:29] CLIENTLike, you know sometimes I believed in flooding and I think that was it, I just.

15 minutes 34 seconds DR. MARTIN ANTONY

[15:34] DR. MARTIN ANTONYYou’re making my job really easy because usually I have to sell it to people but...(crosstalk)

15 minutes 39 seconds CLIENT

[15:39] CLIENTYou know that, thoughts can go over and over and my husband is supportive of what I do, he knows my fears and the first time we flew was to Vegas by plane, he took me to the airport and I watched the airplanes go take off and that helped. DR. MARTIN ANTONY: That’s great. So you’re actually describing what the

15 minutes 59 seconds DR. MARTIN ANTONY

[15:59] DR. MARTIN ANTONYtreatment is for this sort of thing, it’s basically...(crosstalk) CLIENT: I just can’t stop that numbers thing, that’s one thing that drives me nuts.

16 minutes 4 seconds DR. MARTIN ANTONY

[16:04] DR. MARTIN ANTONYYes, we’ll come to that in a moment but certainly what you do with your fear of flying is exactly what, if somebody had a fear of flying and they came to me for help, it’s exactly what we would do that person, so we would help them to expose themselves to what they are afraid of, in a supportive kind of planned way, which is what you and your husband did and it seemed to work well for you. So with this, it’s a little bit different and it’s harder to kind of get a grasp on this because it is not a place, it’s not an object that you’re afraid of, you know if you were afraid of contamination, we could expose you to things that you see as contaminated and...(crosstalk)

16 minutes 44 seconds CLIENT

[16:44] CLIENTIt’s spiders, the only object I’m scared of is spiders. DR. MARTIN ANTONY: Yeah we could do the same thing with spiders, with this.

3: Providing Psychoeducation

16 minutes 49 seconds DR. MARTIN ANTONY

[16:49] DR. MARTIN ANTONYWe’re not going to do that. With this, it’s a little bit more abstract in a way, the rituals are all mental rituals, you’re not washing your hands, well you are a little bit, but that’s not really what the issue is here and the triggers, I guess, are also more abstract, stress kind of makes you do it more but it’s not like a spider, which is a very distinct kind of trigger, so that does make this a little bit more challenging to deal with, but I think what we’ll do is try to figure out a way to apply that principle of exposure to this sort of thing.

17 minutes 24 seconds DR. MARTIN ANTONY

[17:24] DR. MARTIN ANTONYWe’ll do that in a couple of minutes, but I want to highlight some of the things to keep in mind when you’re trying to do an exposure based, you know what you call flooding earlier, basically confronting a situation that you feel rather than avoiding it. You know, there are a number of things that are important to keep in mind and one of those things is the frequency of the practices, so you’ve probably seen planes take off and land before you got over your fear and it didn’t make a difference. What do you think was different about the time with your husband where it did make a difference?

17 minutes 59 seconds CLIENT

[17:59] CLIENTI think it was nice because I had never been to an airport, we actually went there and I was really confident in the thought that if something was going to happen, he was going to be with me.

18 minutes 14 seconds DR. MARTIN ANTONY

[18:14] DR. MARTIN ANTONYOkay. CLIENT: That was very comforting, like that. DR. MARTIN ANTONY: So you had some support and a sense of maybe better sort of control, a sense that if something was to go wrong, you’d have somebody there with you. Anything else different about the exposure that you had then versus other times that you’ve seen planes take off and land? CLIENT: I think just,

18 minutes 34 seconds CLIENT

[18:34] CLIENTlike from the first time? DR. MARTIN ANTONY: I’m just saying, all over your life, when was this experience with your husband?

18 minutes 39 seconds CLIENT

[18:39] CLIENTThat was four years ago. DR. MARTIN ANTONY: Okay. Well, say

18 minutes 44 seconds DR. MARTIN ANTONY

[18:44] DR. MARTIN ANTONY10 years ago or 20 years ago when you’ve seen planes take off and land and it didn’t make your fear go away, what was different about the time with your husband?

18 minutes 54 seconds CLIENT

[18:54] CLIENTI really had no one there, saying oh you know everything’s fine, I’ve never been around airplanes or anything, I just had, I may have seen one on TV when it crashed. DR. MARTIN ANTONY: That’s true, yeah the media...(crosstalk) CLIENT: Yeah so that was the only exposure I had.

19 minutes 9 seconds DR. MARTIN ANTONY

[19:09] DR. MARTIN ANTONYOkay, so the types of exposure you’d had in the past were negative. Another thing that I wanna highlight, that experience with your husband is that the exposure was frequent, I mean it was over and over and over again because you were right by an airport whereas in the past, you’d probably been exposed to airplanes more infrequently...(crosstalk) CLIENT: Yeah. DR. MARTIN ANTONY: And for exposure to be effective, it needs to be done in that over and over and over again kind of way, so even you know once a week isn’t enough for a lot of people anyway to lead to a reduction in fear so usually exposure needs to occur a few times a week and ideally in a prolonged way, so if you just did a little bit of exposure for a couple of minutes, imagine if you were afraid of dogs and you saw dogs a couple of minutes then you ran away, what you would learn from that is when the dog’s there I feel terrified and when I run away, I feel much better.

19 minutes 59 seconds DR. MARTIN ANTONY

[19:59] DR. MARTIN ANTONYSo, in sort of a way, it reinforce your fear whereas with prolonged exposure, people tend to see more of a reduction in fear over time, if they do that again close together over and over and over again. The other thing that seems to be very important during exposure is to do it in a way that is supportive and planned and predictable with no big surprises and again, having your husband there initially for those exposures may have given you that sense of control on the situation. Eventually, we want people to let go of some of that but initially, I think that can be useful for people. So, if we turn our attention to these words, how could we apply this principle to the thing that you do? Any thoughts about that?

20 minutes 44 seconds CLIENT

[20:44] CLIENTThis just drives me crazy, the more I try to think about it, especially those books. Therefore, I brought the books today with my niece and I kept doing it and it’s sort of crazy. DR. MARTIN ANTONY: Any guesses about how you could apply this exposure principle to

20 minutes 59 seconds DR. MARTIN ANTONY

[20:59] DR. MARTIN ANTONYthese books? CLIENT: I mean, if I imagine it’s a word book,

21 minutes 4 seconds CLIENT

[21:04] CLIENTif I just kept staring at it, I’d just push myself doing it over and over again. Every time I feel a little anxiety, I’m going to look at the word and do it and it’ll help me. DR. MARTIN ANTONY: Okay.

21 minutes 14 seconds CLIENT

[21:14] CLIENTNo. I really can’t. DR. MARTIN ANTONY: Okay. Well, with obsessive-compulsive behavior,

21 minutes 19 seconds DR. MARTIN ANTONY

[21:19] DR. MARTIN ANTONYthere are two components to, we’re going to be talking more about a behavorial kind of approach, more than a exposure-based approach to treatment today. There are other strategies that can be used often with OCD cognitive strategies, for example, involve teaching people to change their thoughts about the things they fear. In your case, there aren’t, you aren’t aware anyway of any specific thoughts that trigger this, so we’re going to focus more on the behaviors and there are two components to the treatment. One is exposure to the things that trigger your anxiety and the second component is what we call ritual prevention or response prevention and that’s prevention of the things that you do to get rid of that discomfort. So, in your case, the trigger of the discomfort seems to be the word and the urge to then do the ritual and what we want to do is expose you to those triggers, but have you not do the ritual. Now imagine, let’s talk for a minute about a completely different sort of type of obsessive-compulsive disorder and that’s people who are afraid of contamination and every time they touch something they perceive as contaminated, they go and wash their hands and they might do that, you might wash your hands 5 or 10 times a day, for some people it may be 200 times a day, so it’s taking up hours and hours.

22 minutes 34 seconds DR. MARTIN ANTONY

[22:34] DR. MARTIN ANTONYIn their case, what we would often recommend is that they practice exposing themselves to objects that they perceive as contaminated, just like you did with the airplane and not doing things to get rid of that feeling. And what you think happens, so not washing for example, what you think happens to your anxiety over time?

22 minutes 54 seconds CLIENT

[22:54] CLIENTInitially, I think it would heighten and then probably decline after a while.

22 minutes 59 seconds DR. MARTIN ANTONY

[22:59] DR. MARTIN ANTONYThat’s exactly what happens usually. I mean, usually it goes up and then gradually starts to come down. It may be hard to imagine it now because now we’re talking about something that you’re afraid of but...(crosstalk) CLIENT: Yeah, I don’t see it ever changing.

23 minutes 14 seconds DR. MARTIN ANTONY

[23:14] DR. MARTIN ANTONYBut the same kind of principle can apply to this. This is a little trickier and the reason it’s trickier is because with washing, the stuff that you can do to prevent the behavior, you can even turn off the water in the basement so there is no running water, the triggers are very concrete, right, you can find things that are contaminated, touch them. For you, a lot of it is mental, a lot of it is in your head and that makes it more challenging. You may not see the same kind of reduction as quickly as you would with something like the airplanes, for example, so it would take potentially more practice and more repeated practice and perhaps a longer time to see the kind of change with this sort of thing, but I would like to try it today and again, this is just going to be a short demonstration. In an ideal session, we’d probably need for 90 minutes, it’s been a good 45 minutes doing this and then we do it again the next week and in between you’d be doing on a daily basis, practicing, so it’s a pretty intensive kind of treatment but what we’ll do, we’ll at least give you an idea of the kind of things that you might be able to practice when you leave here and the other thing, have you written, have you read any books about this sort of treatment for OCD?.

24 minutes 29 seconds CLIENT

[24:29] CLIENTNo, I’ve the only exposure to the kind of therapy has been in behavorial, it’s been in class. DR. MARTIN ANTONY: Okay. The other thing that we’ll do is at the end,

24 minutes 39 seconds DR. MARTIN ANTONY

[24:39] DR. MARTIN ANTONYI can also recommend a few books to you, there are a number of really good books on the market, I can write some of those titles down for you and you can check them out. Okay, so is there one of these books that’s a little bit harder than the other? CLIENT: Law Enforcement.

4: Experiential Exposure

24 minutes 54 seconds DR. MARTIN ANTONY

[24:54] DR. MARTIN ANTONYOkay, and typically with exposure, we will often begin with words that are easier and work up to more difficult situations, but we also don’t have to begin with anything too easy. What we want to do typically is begin with something that’s challenging but not so challenging that you can’t do it. So, basically I want to do as much as you’re willing to do. So, to start, would it be too difficult to use the difficult book, or do you think you could do that? Is this the one that you’ve been reading to your niece...(crosstalk) CLIENT: That’s, that’s the hard one, but it doesn’t matter to me any.

25 minutes 29 seconds DR. MARTIN ANTONY

[25:29] DR. MARTIN ANTONYOkay. Let’s give that a try. The advantage is sort of like I often use exercise analogies that if you’re working out or lifting weights or jogging or whatever, if you do a little bit at a time, you’ll become more fit over time but it will happen more slowly. If you do things that are more difficult, you’re more likely to get sore, you’re more likely to get tired, it’s not going to be as pleasant to workout maybe, but you’ll also see changes more quickly and same with dealing with the OCD, that the bigger steps you take, the more uncomfortable you’re going to be and if we try this and if you find it’s too uncomfortable, we can always try the easier thing to you. So, the only thing you have to lose is being more uncomfortable than you want to be, but it sounds like you’re willing to try just a start. Is there a particular part of the book that, is it...(crosstalk)

26 minutes 19 seconds CLIENT

[26:19] CLIENTThey’re all one word, every page is one word and there’s an opposite word.

26 minutes 24 seconds DR. MARTIN ANTONY

[26:24] DR. MARTIN ANTONYOkay, so then I’m going to open the book then and we’ll just open it to a particular page and when I do that, just kind of prepare for what’s going to happen, you’re going to see a word and I assume if it’s an even number you’ll want to start dividing it up, I guess. If it’s an odd number of letters, you’ll want to add letters and then start dividing it up, and what I’d like you to try to do is to not do that. CLIENT: Alright.

26 minutes 54 seconds DR. MARTIN ANTONY

[26:54] DR. MARTIN ANTONYIf anything, to try to do the opposite, especially it’s fitting that it’s a book on opposites, to try to purposely do the very thing that you don’t want to do. So, let that word stay in odd number of letters, for example let the word in your head stay together and again, when something is happening in your head, a lot of it is very automatic, so you’re going need to really focus to sort of prevent yourself from doing that and actually I should ask you that, is that something that does happen automatically for you or do you feel like it is something that you’re purposely doing? CLIENT: Mainly it’s

27 minutes 29 seconds CLIENT

[27:29] CLIENTautomatic, automatic. DR. MARTIN ANTONY: Okay.

27 minutes 34 seconds DR. MARTIN ANTONY

[27:34] DR. MARTIN ANTONYThe other thing, you know we won’t do today but normally what I would do with people is have them begin to monitor the behavior, to bring it more into their awareness. So we would actually develop a form where people will actually monitor the number of times they do this or if it’s something that’s happening all the time, they might monitor the frequency over the course of each hour of the day, for example, so they might you know for 9-10 in the morning they might record they did it 60% of the time something like that but if it’s something that you can actually identify specific episodes, we’d have you monitor those because to change the behavior, we need to make it less automatic.

28 minutes 14 seconds DR. MARTIN ANTONY

[28:14] DR. MARTIN ANTONYJust like if we’re helping somebody to eat more healthy, we’d probably begin by having them just monitor what they are eating, so they’re not just eating without thinking, or if we are helping someone to stop biting their nails, first we’d have to get them to become more aware of the behavior, so. Okay, so you’re ready for me to just open the book? Okay. So I’m just going to open to a particular page, so you’ve got a word there and again, I want you to focus, so this the word order, like you just focus on the word and focus on trying to keep that word together without dividing it up and I’m going to ask you to let me know how anxious you are, how uncomfortable you are, using a scale ranging from 0 to 100 where 0 is, this doesn’t bother me at all, 100 is, this is completely overwhelming and 50 would be it’s bothering me, but I can manage it.

29 minutes 4 seconds CLIENT

[29:04] CLIENT75%. DR. MARTIN ANTONY: Okay, so pretty intense but not overwhelming.

29 minutes 9 seconds DR. MARTIN ANTONY

[29:09] DR. MARTIN ANTONYOkay and how successful are you right now at being able to keep it as one word?

29 minutes 14 seconds CLIENT

[29:14] CLIENTWell, the second you opened it, the first thing I did was that. The first thing I did was, even it out and then now I’m trying to keep it all together and it’s, and now what I’m finding, I’m doing it instead of evening out, separating it. DR. MARTIN ANTONY: As soon as you notice it,

29 minutes 34 seconds DR. MARTIN ANTONY

[29:34] DR. MARTIN ANTONYyou have to do that, bring it back together. So, don’t keep, normally you would keep going right? And divide it up and...(crosstalk) CLIENT: Yeah, just like I keep saying the word in my head, just say the word in my head and then

29 minutes 44 seconds CLIENT

[29:44] CLIENTI won’t do it if I’m busy. DR. MARTIN ANTONY: And then do that for now, but really focus on trying to

29 minutes 49 seconds DR. MARTIN ANTONY

[29:49] DR. MARTIN ANTONYkeep that word together. CLIENT: Right now, I’m counting how many times to say it.

29 minutes 54 seconds DR. MARTIN ANTONY

[29:54] DR. MARTIN ANTONYOkay. CLIENT: Great. DR. MARTIN ANTONY: And that’s another thing that you need to watch with, particularly with this sort of obsessive-compulsive behavior where a lot of it is in your head, you can easily replace a ritual with a new one, so we want to be, again as much as you can, to try not to do that and instead focus on trying to keep that word together and what’s your anxiety level now out of a 100?

30 minutes 24 seconds CLIENT

[30:24] CLIENTThe same, maybe a little less, but...(crosstalk). DR. MARTIN ANTONY: Okay, so about 75 - 72.

30 minutes 29 seconds CLIENT

[30:29] CLIENTYeah, 70. DR. MARTIN ANTONY: 70, okay.

30 minutes 34 seconds DR. MARTIN ANTONY

[30:34] DR. MARTIN ANTONY[sil.] Is there anything happening to the word as you stare at it? CLIENT: Yeah.

30 minutes 54 seconds CLIENT

[30:54] CLIENTI’m trying not to read it, I’m staring at it but I’m staring one part of it, so the other part is kind of go away, I don’t see anymore.

31 minutes 4 seconds DR. MARTIN ANTONY

[31:04] DR. MARTIN ANTONYOkay, try to read the word and maybe pay attention to the whole thing and keep it together as a word. You may find it starts to sound funny or you sort of like when you’re a kid and you say your name over and over again, it starts to sound weird. You may find staring at the word that starts to happen with the word, but try to stick to the word order, look at the whole word, read the word and not break it up. CLIENT: It’s hard because a part of the word is a word by itself,

31 minutes 29 seconds CLIENT

[31:29] CLIENTthat’s the biggest problem right now. DR. MARTIN ANTONY: Okay,

31 minutes 34 seconds DR. MARTIN ANTONY

[31:34] DR. MARTIN ANTONYso the word ‘or’. CLIENT: Uh-huh. DR. MARTIN ANTONY: Okay. CLIENT: Something or,

31 minutes 39 seconds CLIENT

[31:39] CLIENTthat sounds playing up into it. DR. MARTIN ANTONY: Do you think you would be a better practice to find a different word?

31 minutes 44 seconds CLIENT

[31:44] CLIENTI don’t know. It might be, maybe.

31 minutes 49 seconds DR. MARTIN ANTONY

[31:49] DR. MARTIN ANTONYLet’s give that a try. We’re going to find a word that. This one, I think, may work better because it’s one syllable and you can’t break it up in the same way, so this is the word light. How’s your anxiety looking at that? CLIENT: The second you put it down, I did it...(crosstalk)

32 minutes 24 seconds DR. MARTIN ANTONY

[32:24] DR. MARTIN ANTONYOkay. CLIENT: And then I stopped and then I just keep saying

32 minutes 29 seconds CLIENT

[32:29] CLIENTthe word in my head, in my head and some anxiety was like 80 for it and then also and I was down, now it’s back up as I do it again.

32 minutes 39 seconds DR. MARTIN ANTONY

[32:39] DR. MARTIN ANTONYOkay. So the urge to do is very strong. CLIENT: It’s stronger than the other word. DR. MARTIN ANTONY: Yeah, okay.

32 minutes 44 seconds CLIENT

[32:44] CLIENTBecause now there isn’t to distract me from it, keep looking at or enduring that as one word, I can’t do anything else with it. DR. MARTIN ANTONY: Okay, so let’s just practice

32 minutes 54 seconds DR. MARTIN ANTONY

[32:54] DR. MARTIN ANTONYlooking at this word and is your anxiety still at 80 or has it come down a bit?

32 minutes 59 seconds CLIENT

[32:59] CLIENTIt’s a little higher. DR. MARTIN ANTONY: It’s higher now. Okay.

33 minutes 4 seconds DR. MARTIN ANTONY

[33:04] DR. MARTIN ANTONYAnd that’s not unusual. A metaphor that I like to use sometimes with doing this sort of work is, in a way obsessive-compulsive disorder is sort of like a spoiled child in a way that’s used to getting its way and just like a spoiled child is used to getting a toy whenever it screams for a toy, the OCD is used to being able to do the ritual and with the child, the more you give the child the toy or candy or whatever, the more you reinforce the behavior and the ritual has the same effect with the OCD.

33 minutes 39 seconds DR. MARTIN ANTONY

[33:39] DR. MARTIN ANTONYWhat happens when you stop giving the child the toy or candy, a spoiled child? CLIENT: Throws a fit. DR. MARTIN ANTONY: Yeah. Right, so the OCD now is just throwing a fit, it’s going up, it’s getting worse, it doesn’t like this, it wants to do a ritual and what happens eventually with the child?

33 minutes 59 seconds CLIENT

[33:59] CLIENTStarts to calm down and accepts the fact that it can’t get it. DR. MARTIN ANTONY: Yeah, exactly.

34 minutes 4 seconds DR. MARTIN ANTONY

[34:04] DR. MARTIN ANTONYAnd the OCD will do the same sort of thing as well, so it will shoot up and eventually that anxiety will come down and it may come down in 5 minutes, it may come down in 45 minutes, so again we may not get to that point today but at least you’ll have an idea of what to do with this sort of thing. So I’m distracting you, so I wanna bring you back to this. CLIENT: Sort of, I didn’t know it was rude for me to say that, what you’re talking.

34 minutes 29 seconds DR. MARTIN ANTONY

[34:29] DR. MARTIN ANTONYYeah, that’s fine. I have to be careful because when I start talking, it can actually...(crosstalk).

34 minutes 34 seconds CLIENT

[34:34] CLIENTSo like my head is pounding because I keep just saying that a little more in my head, and it’s terrible. DR. MARTIN ANTONY: There are different ways you can do this,

34 minutes 44 seconds DR. MARTIN ANTONY

[34:44] DR. MARTIN ANTONYyou can certainly spend some time focusing on the word and not doing the ritual. The other thing you can do is just flip through the book and look at multiple different words so you’re not just focused on one. So, mixing it up, I think, is helpful. The advantage of mixing up the practice and doing it in a different way is that you also don’t fall into a pattern of replacing that ritual with a new one because you know one thing, you just said you’re repeating the word in your head. You know, some people that I’ve worked with have had a situation where the thing that they’re doing to try to prevent the ritual itself becomes a ritual, where now I feel like I’ve to repeat the word in my head over and over and over and over again.

35 minutes 24 seconds DR. MARTIN ANTONY

[35:24] DR. MARTIN ANTONYWe don’t that to happen either. So, maybe I’m mixed up a little bit now and just turn to some other word, would that be okay? CLIENT: Yeah, that’s fine. DR. MARTIN ANTONY: Okay and you may, as soon as you see, it’s so automatic, this process, you may, as soon as you see the word, start to do it but that’s fine, but try to bring yourself back to sort of like the difference between being startled and being terrified. Startled just lasts, it’s something when something first happens, you get startled but then that dies down quickly whereas with fear, that might last quite a bit longer. If initially you engage in some sort of automatic ritual that’s fine, but try to bring yourself back.

36 minutes 4 seconds DR. MARTIN ANTONY

[36:04] DR. MARTIN ANTONYHow’s your anxiety, by the way, now looking at this? CLIENT: I want it to go away.

36 minutes 9 seconds DR. MARTIN ANTONY

[36:09] DR. MARTIN ANTONYOkay. CLIENT: It’s heightened. DR. MARTIN ANTONY: So it’s quite high, okay. And when you say that, that makes me think that we should maybe stick with this for a bit. CLIENT: Okay, then lets slow,

36 minutes 19 seconds CLIENT

[36:19] CLIENTso that we don’t look at it. Because now you said switch and I’m thinking okay, now it’s like I can go to dark and that the uneven words bother me, so much wondering. DR. MARTIN ANTONY: Okay, you know let’s keep flipping that, that was

36 minutes 34 seconds DR. MARTIN ANTONY

[36:34] DR. MARTIN ANTONYthe plan, again if we had more time, I might stick with this longer. So this is the word, concrete. CLIENT: Just looking at it,

36 minutes 49 seconds CLIENT

[36:49] CLIENTmakes it worse...(crosstalk) DR. MARTIN ANTONY: Okay, so this is another odd number of letters.

36 minutes 54 seconds CLIENT

[36:54] CLIENTI don’t know, I haven’t counted the alphabets, I’m focusing on the C.

36 minutes 59 seconds DR. MARTIN ANTONY

[36:59] DR. MARTIN ANTONYOh you know it’s not odd anyway, it’s even. CLIENT: I just did it.

37 minutes 4 seconds DR. MARTIN ANTONY

[37:04] DR. MARTIN ANTONYSo if it’s even, then that makes you want to start to writing it up, is that right?. CLIENT: If I know it’s even then I do it right away and

37 minutes 14 seconds CLIENT

[37:14] CLIENTknow if it’s on. DR. MARTIN ANTONY: And once you’ve done, it’s done. CLIENT: Yeah. DR. MARTIN ANTONY: Okay. CLIENT: The one’s done is done.

37 minutes 19 seconds DR. MARTIN ANTONY

[37:19] DR. MARTIN ANTONYOkay. Just look at this letter. So it’s the word dirty. CLIENT: I just keep saying it over and over in my head

37 minutes 34 seconds CLIENT

[37:34] CLIENTand I’m not doing it but keep saying it over and over again. DR. MARTIN ANTONY: Can you not say it and just look at it

37 minutes 39 seconds DR. MARTIN ANTONY

[37:39] DR. MARTIN ANTONYand try not to?

37 minutes 49 seconds CLIENT

[37:49] CLIENTSo far, so good. DR. MARTIN ANTONY: Okay. Part of it is, I don’t know how to divide it up, that’s my problem I don’t know what to add on to make it even, so that’s my biggest problem right now. DR. MARTIN ANTONY: Okay. CLIENT: That’s what...(crosstalk).

38 minutes 4 seconds DR. MARTIN ANTONY

[38:04] DR. MARTIN ANTONYYeah if you mind it’s not like, you know, sometimes the more you try to control thoughts, if you’re trying not to think of a pink elephant, you’ll just start thinking of a pink elephant. CLIENT: I love that saying. It was a pink elephant. DR. MARTIN ANTONY: With this, if you find your mind drifting into some sort of thought that’s fine, just let it go and bring yourself back to what you’re doing though and the main thing is if you’re feeling anxiety about looking at it, then, then that’s the thing you should be doing so the real base for you is if you’re anxiety is telling you not to do something, then that’s probably the thing you should be doing, that’s why I wanted to just stick with the word light because you had a strong urge not to look at that word.

38 minutes 44 seconds DR. MARTIN ANTONY

[38:44] DR. MARTIN ANTONYWhat’s your anxiety now with this?

38 minutes 49 seconds CLIENT

[38:49] CLIENTIt’s fine, I’ve divided it, I haven’t evened it.

38 minutes 54 seconds DR. MARTIN ANTONY

[38:54] DR. MARTIN ANTONYCan you give me a number out of 100 for this? CLIENT: Let’s say about 35.

38 minutes 59 seconds DR. MARTIN ANTONY

[38:59] DR. MARTIN ANTONYIs that because this is getting easier or just because this is an easier word than the other one?

39 minutes 4 seconds CLIENT

[39:04] CLIENTJust because that word is hard to divide up and I’m not focussing on it. DR. MARTIN ANTONY: Okay.

5: Session Reflections

39 minutes 9 seconds DR. MARTIN ANTONY

[39:09] DR. MARTIN ANTONYI want to stop doing this for now, not because we’ve gotten to the point where normally we would stop, just because we’re getting low on time and I would like to take a moment to talk about some of the other issues that you’ve mentioned but this is the kind of thing that we would normally recommend that you really spend some time working on, on a daily basis and when it does come up in everyday life, to take advantage of that as an opportunity to not do the ritual, if you can, but also in addition to everyday life, purposely bringing it on with a book like this, for example. The other two things that we talked about were the cleaning and having to clean in a ritualized orderly way and the other piece was the morning rituals.

39 minutes 59 seconds DR. MARTIN ANTONY

[39:59] DR. MARTIN ANTONYFrom a treatment perspective, those are way easier to do something about, just because they’re very specific behaviors that you can do, it’s not all in your head, it’s actually stuff that you’re doing. What you think, based on what we’ve spoken about so far, what do you think you would do to change those behaviors. If we begin with, say the cleaning rituals, having to clean in a certain order?

40 minutes 19 seconds CLIENT

[40:19] CLIENTI don’t know, I’ve done that for so long. That all started when my mom would put on the list, we would put a list on the refrigerator, what I had to do so, say vacuum floor, mop, blah, blah,blah. That’s how it started and then I just took it a lot further. I see the morning rituals, it’s just not a strict ritual, I see that breaking easier than the than the cleaning. The cleaning, I’ve done that for so long that I just don’t see it.

40 minutes 54 seconds DR. MARTIN ANTONY

[40:54] DR. MARTIN ANTONYIs that something if you could wave a magic wand, is that something you would want to change? Say, you see, you could change it. CLIENT: No, the only thing I say would encourage

41 minutes 4 seconds CLIENT

[41:04] CLIENTchanges because my house is very clean after I’m finished. That’s the only reason why, because I don’t see a harm in doing that.

41 minutes 14 seconds DR. MARTIN ANTONY

[41:14] DR. MARTIN ANTONYWell I guess one question is does it take up too much time, so is it stopping you from doing other things that are important or this is affecting your relationships or your schoolwork or getting in the way of doing things that are enjoyable. CLIENT: I’m a procrastinator, especially when it comes to my schoolwork

41 minutes 29 seconds CLIENT

[41:29] CLIENTand I use cleaning and all that stuff as a distraction for me to procrastinating longer on doing my work. DR. MARTIN ANTONY: Okay, so in that way it kind of

41 minutes 39 seconds DR. MARTIN ANTONY

[41:39] DR. MARTIN ANTONYfeeds into the procrastination. Okay, so gets in the way at least in that way I guess a little bit. Does the morning ritual cause more problems for you or?

41 minutes 54 seconds CLIENT

[41:54] CLIENTThe only time when ritual bothers me is when my husband will call me in the morning and try to talk to me and he has to understand that I don’t talk to anybody in the morning. DR. MARTIN ANTONY: Okay. CLIENT: I don’t like to talk to anybody.

42 minutes 4 seconds DR. MARTIN ANTONY

[42:04] DR. MARTIN ANTONYSo how would you change that, how you know? CLIENT: Turn my phone off, but I don’t want

42 minutes 9 seconds CLIENT

[42:09] CLIENTmy phone off because if something happens to him, I want to, you know. DR. MARTIN ANTONY: How would you change the morning ritual.

42 minutes 14 seconds DR. MARTIN ANTONY

[42:14] DR. MARTIN ANTONYIf you were, from an exposure perspective, what would we do if were going to target that as part of the treatment? CLIENT: Probably,

42 minutes 24 seconds CLIENT

[42:24] CLIENTI’d say get up earlier, maybe eat breakfast before. take the shower and all that and then.

42 minutes 29 seconds DR. MARTIN ANTONY

[42:29] DR. MARTIN ANTONYYeah, so we’d basically are breaking the rules. Doing things out of order, skipping steps. CLIENT: Yeah.

42 minutes 34 seconds DR. MARTIN ANTONY

[42:34] DR. MARTIN ANTONYAnd same with the cleaning...(crosstalk) CLIENT: I can’t skip any stuff in the morning though. DR. MARTIN ANTONY: There are certain things you just have to do, but there are probably some things that you can do out of order or do differently. Do you eat the same thing for breakfast everyday? CLIENT: No. DR. MARTIN ANTONY: Okay. CLIENT: It depends on what I feel like

42 minutes 49 seconds CLIENT

[42:49] CLIENThaving in the morning. DR. MARTIN ANTONY: And with the cleaning, you know you could start to clean out of order or

42 minutes 54 seconds DR. MARTIN ANTONY

[42:54] DR. MARTIN ANTONYskip a cleaning one day or not have a list. Again, I know that...(crosstalk) CLIENT: Pretty hard to do. DR. MARTIN ANTONY: I know as I describe these things, they sound very, very difficult. From an exposure perspective, we come up with a way to have it been manageable, to do it maybe starting with something small that’s a little bit anxiety provoking but not overwhelming, having you practice that over and over again and then moving up to changing things a little bit more,

6: Session Closes

43 minutes 19 seconds DR. MARTIN ANTONY

[43:19] DR. MARTIN ANTONYagain perhaps, so we just have another few seconds, so I just wanna ask you, is there something you could do over the next week, with respect to any of these three areas differently, something you could practice a few times over the next week. CLIENT: During the day,

43 minutes 39 seconds CLIENT

[43:39] CLIENTI have a lot of free time on my hands because you know, a lots of time I sit there and I read that’s where I usually do my homework. I could possibly bring some books with me and do a little bit of that. DR. MARTIN ANTONY: Do you think that time to try that 3 or 4 times for a good half hour over the next week?

43 minutes 59 seconds CLIENT

[43:59] CLIENTYes, I have time to do that because I don’t do much.

44 minutes 4 seconds DR. MARTIN ANTONY

[44:04] DR. MARTIN ANTONYOkay, great and again the more you do with it, the more change that you’ll see so you can certainly do it more than that if you want. CLIENT: So, I can go to reading a kid book, you know my students won but. DR. MARTIN ANTONY: You can also do some of the stuff in privacy, if you go off for lunch or something, do it in the car, or even something like that. So, great, that’s good. I really appreciate your coming in and doing this and hope it was helpful for you.

44 minutes 29 seconds CLIENT

[44:29] CLIENTYes it was actually helpful. Thank you. DR. MARTIN ANTONY: You’re welcome.