Treating Scrupulosity and Other “Bad Thoughts”: Jed Siev

I met today’s guest, Jed Siev, PhD, several years ago at an OCD conference—I think Lee Baer introduced us, and as I mention later in the Q&A, I loved Dr. Baer! One of the reasons I loved him was that he was truly and deeply empathetic toward sufferers of “taboo obsessions” (i.e., me) and worked hard to ease the immense pain they can cause. Jed, too, has dedicated so much time to studying these distressing thoughts and how to help people address them. As long as people like Jed exist, we’ll never stop learning about OCD and how people who have it can live richer, fuller lives despite it. Thank you, Jed, for all you do!

As a therapist you treat not only OCD but body dysmorphic disorder (BDD), hoarding, hair pulling and skin picking, and tic disorders. How are these disorders related? Are there treatment methods they have in common?

In DSM-5, all of those except for tic disorders are classified as “Obsessive-Compulsive and Related Disorders.” To varying degrees and with respect to varying factors, there is overlap among them. Some co-occur at higher rates than chance, some share fundamental features, some respond to similar treatment approaches. For example, OCD and BDD are characterized by obsessions and compulsions, and first-line treatments for both are similar (CBT including ERP). It is probably worth noting that some have questioned the validity and utility of this grouping.

Tic disorders are not classified with the others, but behavioral treatments for tic disorders often include techniques that are also part of treatments for body-focused repetitive behaviors (e.g., hair pulling and skin picking) such as habit-reversal training. There are also manifestations of OCD that Charles Mansueto and colleagues have called “Tourettic OCD,” and the diagnostic criteria for OCD actually include an optional specifier to indicate it is “tic-related.”

You’re also an associate professor in the Department of Psychology at Swarthmore College. I’ve often heard from folks who’ve taken psychology courses that OCD was taught for maybe a day or two at most, and the classes barely scratched the surface. With your focus on OCD and related disorders, are you able to delve more deeply into the topic?

For better or for worse, I do, and I joke that my students are a captive audience. In Clinical Psychology (what many institutions call Abnormal Psychology), we spend about a week and a half on OCD and related disorders, but I also end up using many OCD-related examples throughout the semester simply because I have more to draw on from my clinical work. It’s tough because there are so many things to cover in an overview class like that. I also teach a seminar on anxiety disorders, and we spend one week on OCD and another week on “OC spectrum” disorders such as BDD and hoarding.

Do students in your psychology classes come with a fairly good knowledge of what OCD is, or does it seem like most associate it with what we often see portrayed in media, such as excessive hand washing and needing things to be organized a certain way? Have you seen a shift at all over time in how well versed students are in the topic?

I think there’s a lot of variability in terms of how sophisticated the students’ pre-class knowledge is. I’ve had students with OCD or with family members who have OCD in my classes, and when they’ve chosen to tell me about it, I’ve usually been pleasantly surprised to find they’ve received accurate information and quality treatment. Other students have more stereotyped or caricatured impressions of OCD, or simply don’t know much about it at all. I confess that I was probably one of those students when I was an undergraduate.

I hadn’t noticed a shift in the time I’ve been teaching, but I started my first faculty position in 2011, which wasn’t long before more nuanced portrayals of OCD were mainstream (e.g., in Girls).

You trained with one of my favorite people ever, Lee Baer, the author of The Imp of the Mind: Exploring the Silent Epidemic of Obsessive Bad Thoughts. These “bad thoughts” include violent, religious, and sexual obsessions, which Dr. Baer also referred to as taboo obsessions. Why did you decide to focus some of your research on these types of thoughts?

Well first of all, Lee Baer was also one of my favorite people! As I imagine is true of many people, I lucked my way into so much of what I do now. Credit really goes to a series of fortuitous twists and turns.

I went to graduate school to study child anxiety without any interest in OCD. However, I was placed with Jon Grayson for my first treatment practicum, and I finally really understood OCD. I discovered, as well, how rewarding it is to work with folks who can be so severely impaired but for whom treatment can be so effective and life changing. I was hooked.

The following year, I worked with Edna Foa and Jonathan Huppert. We had a steady referral stream from a nearby Ultra-Orthodox Jewish community, and I was able to learn a lot about treating scrupulosity, which in turn got me interested in unacceptable thoughts symptoms more broadly.

Having OCD can make a person feel guilt and shame, and although there’s no obsession or compulsion any of us are particularly proud of, there is another layer of shame and guilt with taboo obsessions. Are there elements of therapy that address some of that guilt and shame, or steps a person can take to ease some of it?

You’re certainly right about the extra layer of shame and guilt. The way I often think about it is that taboo obsessions are extra distressing because people experience them as a threat to their sense of self—who they are—not just what might happen. I actually have been thinking (and reading and listening) a lot recently about how to address shame and guilt, and I’m not sure I have it fully worked out. But here are some of the pieces.

Cognitive techniques can be helpful to explore moral judgments and decision-making, and to clarify one’s actual beliefs—as opposed to fears—about the meaning of taboo obsessions. Are you engaging in emotional reasoning, whereby instead of feeling guilt because of your beliefs and judgments, you infer from your sense of guilt that something must be wrong? (A former graduate student of mine had some data showing that symptoms of scrupulosity were associated with that sort of reasoning.) There are also a number of questions that can help clarify sources and/or targets of shame. For example, are there double standards in how you judge yourself versus others? Is the shame about what you imagine others would think of you?

I think the therapeutic relationship can also be an antidote to shame. It can be powerful to reveal your most shameful thoughts, images, and urges to someone and discover that they feel empathy and care, and don’t seem to view you differently—that they respond to the “shameful” obsessions as matter-of-factly as to the relatively boring ones.

When I first met with an OCD specialist after struggling with sexual and religious obsessions for over a decade, I was afraid I wouldn’t be able to get the words out and tell him what I’d been experiencing. I was afraid he’d have no choice but to report me to the authorities! Luckily he knew these thoughts were OCD symptoms and he barely batted an eye, but there have been some instances where a misguided therapist has reported a person who’s voiced some of their harm obsessions. First, what would you tell a person who wants professional help but is afraid this might happen to them, and second, how can we make sure all therapists, regardless of their specialty, know enough about OCD that they don’t mistake it for something dangerous?

I remember hearing you talk about that experience at a conference a number of years ago. So powerful, and an example of at least part of what I meant about the therapeutic relationship.

Sadly, I have also met people who have received harmful information or reactions from misguided therapists, including being told that obsessional fears were actually true-but-unwanted desires, let alone actually being reported. Unfortunately, I don’t think this is completely unrealistic, so I think it would be disingenuous or at least glib to just say that one should always simply “tolerate the uncertainty” and take the risk. Rather, I think someone needs to make an honest assessment of how rational the fear is in their particular situation, so they can take a more calculated risk. Find a therapist or support person who understands OCD. Anyone who specializes in OCD will have many experiences with people who have obsessions at least as horrible as yours. I imagine that someone reading this blog knows something about how to find qualified resources for OCD, including treatment providers, but the IOCDF is a great place to start.

I wish I had a good answer for how to ensure that therapists won’t mistake a benign but scary obsession with something dangerous. I’m all ears!

If you could offer just one piece of advice to someone with OCD, what would it be?

Treatment works! Yes, it is hard work, and yes, it may seem intimidating. Find someone who can help you work at a pace you can tolerate and in a way that respects your non-OCD beliefs and values (e.g., in a case of religious scrupulosity). You really truly can live a “normal” life, unburdened in your everyday experiences from the grip of OCD. And through organizations like the IOCDF, there is a wonderful community of people who have been through it and are eager to support you.