Welcome to the first episode of SEASON 2 of Lively Minds!
In this episode, we will be talking to Stuart Ralph who featured in what is currently our most popular episode of season 1, exploring OCD: Obsessive Compulsive Disorder.
Stuart is a counsellor and psychotherapist for children and young people, who has lived experience of OCD, is the co-founder of the Integrative Centre for OCD Therapy and host of the very popular OCD Stories podcast which we recommend you check out.
In today’s show, Stuart will be chatting to us about a strand of OCD known as “Pure O”. We’ll be finding out what it is, why – despite its existence being contested, why the term has been embraced by so many within the OCD community.
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Please note that this show does not constitute medical advice and is not a replacement for seeking professional help. You can find our more about the show and get signposting to support on our website anyamedia.net/livelyminds
W: Hello, my name is Will.
E: And my name is Ellie.
W: You are listening to Lively Minds, the podcast about mental health challenges that go beyond the ebb and flow of the everyday.
E: The podcast that looks at how developing our understanding of mental health issues influences how we address them.
W: In this episode, we will be talking to Stuart Ralph, who featured in what is currently our most popular episode of season one, exploring OCD, Obsessive Compulsive Disorder.
E: Stuart is a counsellor and psychotherapist for children and young people who has lived experience of OCD, is the co-founder of the Integrative Centre for OCD Therapy and host of the very popular OCD Stories podcast, which we really recommend you check out.
W: In today’s show, Stuart will be chatting to us about a strand of OCD known as Pure O. We’ll be finding out what it is and why, despite its existence being contested, the term has been embraced by so many within the OCD community. Welcome back on the show, Stuart.
S: Thank you for having me back on. I’m honoured to hear that it’s the most popular episode! That’s really flattering and great to be back on talking with you guys.
W: Thank you. It’s great to have you.
E: To begin with, could you remind us, particularly for the benefit of people who aren’t so familiar with it, how you define OCD?
S: Yeah. So it’s best just to break it down into the O and C. So obsession, compulsion. Obsession could also be named intrusive for, image, urge, impulse. Often they call it ego dystonic. It’s against what we want. It’s repugnant to us. That’s why it’s scary to the person. They don’t want these thoughts and feelings, these sensations. they want none of it. They can come in different themes, sometimes called subtypes of OCD. It could be worried about physical contamination, emotional contamination, worrying about offending your God. You’d call that religious OCD, obsessively worrying about your romantic relationship, called relationship OCD. Worrying about sort of harming someone, hurting someone, killing someone. We might call that harm OCD. You could also have paedophile-themed OCD, which is where you’re worried that you’re a paedophile. And of course, people that have those worries, far from being a paedophile, they’re deeply disgusted and scared by that thought. Because they’re deeply disgusted and scared by that thought, they then do compulsions.
Compulsions are any actions in our heads or in the outside world, like mental reviewing is a mental compulsion going over memories or facts and figures. Physical compulsions could be googling, it could be checking, it could be flipping a light switch on and off, washing your hands, hiding knives if you’re worried about killing someone and the reason they do compulsions is to get rid of, remove, reduce, the thoughts and feelings. And then I just mentioned feelings, so that’s not in the title OCD, but the feelings are really what fuels OCD so it’s usually anxiety although it can also be guilt, shame, disgust you name it that also drives the OCD but it’s more common that it’s anxiety but I’ve worked with clients that don’t really have much anxiety and it’s mainly disgust or guilt is the driving emotion behind it. And quite often if we didn’t have those, I say we, because I’ve experienced OCD, I talk a bit about my story in the first episode. When we don’t have those feelings, it doesn’t really matter if we have intrusive thoughts, obsessions, because they don’t bother us.
So there was a study done, it’s probably over 10 years ago now, it was like 94 and 96% of people have intrusive thoughts. So that was general public that were questioned and I think the other, whatever it was, 6% was probably lying or just didn’t realise it. But we all have that image if we stand too close to a train track our brain throws us on the tracks. Most of us have had that thought right? Or you’re holding your kid and suddenly your brain throws your kid down the stairs. Not literally but in your mind. That’s an intrusive thought, it’s scary. Now, but if you’re seriously anxious at the time of having that thought, that thought sticks around and it becomes more and more recurrent in your head and it will keep coming back and back and that’s the OCD cycle and then we do compulsions and what the compulsions teach our brain is that this thought is, could be real, it could be a real danger, because it’s a real danger I better do these safety behaviours or compulsions, but that just reinforces the cycle and teaches our brain we should be afraid of these thoughts therefore we end up doing more compulsions because we’re more anxious, so it’s this vicious cycle of OCD and it really keeps people trapped.
The last thing I say about it is these thoughts are so far fetched often, they’re so far out there. You know just because I had a thought about let’s say Jesus in some kind of sexual way and if I’m a Christian, I might get super worried about that, of course I don’t want to do anything sexual to Jesus, but because I’ve had that thought I’m now obsessed worried about it and can’t stop thinking about it, praying compulsively. That’s just teaching my brain the thought could be real and I get stuck in this cycle. But it’s just far-fetched, right?
E: Thank you. That’s really thorough, today we’re going to talk about something called Pure O which I wasn’t too familiar with until we spoke to you and Will told me about it after the first episode you did with us. So what is Pure O and how does it differ from more traditional understandings of OCD?
S: Yeah, so Pure O is, is highly contested and arguably a bit controversial, which we’ll talk about in a bit, but its, it means purely obsessional, right? So the assumption is there are no compulsions. Now that is the problem with the wording of Pure O, because there’s always compulsions. But the compulsions for people with Pure O are mainly in their head. So they’re doing compulsions in their head as opposed to the physical world. That’s not entirely true, and I’ll share that in a bit when we talk about maybe the issues with the term of Pure O, but in theory it means compulsions are in the mind, not in the physical world, so I’m mainly doing compulsions like checking memories or making lists in my head or saying words in my mind to counteract the thought. It’s those sort of things and it’s also a word for, that could be called rumination. We all ruminate but with OCD it’s very prevalent. I could just call that seriously overthinking. So that’s where it, it got its name. Now it was coined by Dr. Steven Phillips and he’s been on my show like 10, not 20, 10 to 12 times and he coined the term in 1988 because he was seeing a lot of clients come through his practice who didn’t seem to have any physical compulsions, were having these intrusive thoughts often quite taboo intrusive thoughts like violent sexual intrusive thoughts, and they were being missed in the research. So he coined the term to try and bring them into the term OCD.
Now they were always OCD but they were getting missed by other therapists and researchers because they didn’t seem to be washing their hands or checking things over and over again in the real world. So that’s where Pure O came about and it’s been a very useful term because it’s helped people find others who don’t seem to have many physical compulsions. So it’s helped them find a tribe and again I think we’ll talk about that later. But yeah, in short, it’s just where there’s not any physical compulsions or many and it’s mainly mental compulsions but the issue with the wording is purely obsessional to anyone outside would say well that means there’s no compulsions because it’s purely obsessional right? if we’d be very anal about it and that’s why a lot of, not a lot, there are therapists and researchers out there who hate the term. And there are many therapists that actually like the term for the reasons I’ve said that it’s helped people find a tribe. So it’s a real, it’s a problematic term, but it also has had a lot of uses over the years, good uses, and has helped a lot of people feel understood. But yeah, just that misconception of, if anyone says they’ve got Pure O and they don’t do compulsions, lie, unintentional lie, they are doing compulsions, just mainly in their head.
W: Yeah, as you say, yeah, it’s not a formal diagnosis, is it? And it is, as you say, strongly contested within the OCD community and yet it’s been adopted by a lot of people for whom it’s become quite an important idea. Why do you think some people are so drawn to that term?
S: I think it just helped them think this is me. You know, this is, I’m not doing any of these physical things. So I think it’s just help them feel understood and then it’s help them go on Instagram, Twitter, wherever, Facebook, find support groups or hashtag Pure O or advocates like Chrissy Hodges who’s very much on the bandwagon of the term Pure O. She’s a friend of mine and you know she’s all about that. So it’s allowed people like her to have a platform and create lots of videos and share information around. I mean look, you, you can have like let’s say the taboo sexual violent themes of OCD and also have many physical compulsions like you hide knives because you’re worried you’re going to stab someone or, but then you can also have those taboo intrusive thoughts and you don’t do any of that physical stuff it’s all in your head. So, but often, I think people with more what they’d call just intrusive thoughts go under the label of Pure O. Again it’s not, it’s so hard to clear cut to find OCD because it’s not clear cut. You’ve got to draw the line somewhere, which is why I hesitate in always doing it because it’s not clear cut. And when everyone does do that, I don’t like it because it’s not that clear. And we have to be much more fluid when talking about OCD because always people then go, well, I don’t meet that ’cause you said this and it’s like, well, and people with OCD do read into things a lot. And I can say that being someone with OCD. So you’ve always got to be careful in how you talk about it, ’cause especially if they’re triggered, this doesn’t mean me, therefore I don’t have that. Or they start to get anxious because I thought I had Pure O, now Stuart said this, maybe I don’t have Pure O, and it’s never that black and white. And again, OCD wants black and white, and that’s one thing I didn’t talk about, it’s uncertainty, it’s one of the key things of OCD.
W: I wonder to what extent recognising purely mental compulsions is to do with recognising that there are some compulsions that exist on the same turf as the obsession. So what I mean by that is, you know, if I have an intrusive thought, a worry about harming somebody, for example, and then I become worried that I want to harm somebody, even though, as you say, the opposite is actually the case. It’s just that that thought has entered my head and I feel like I need to do something to counter it. That countering action, if it’s internalised and, and, entirely mental, it’s kind of in that same space. And I guess there’s potentially blurring of boundaries as well between the obsession and the compulsion, which I guess, could that be another reason why Pure O has got this idea of being just one half of the OCD whole, as it were, do you think? Even though that isn’t correct, I realise that. But just because of that slight blurring of boundaries that might take place.
S: Yeah, that’s a really good point. So often people, if someone does have OCD and they say they’ve got Pure O, but they say,
“No, I don’t have any, Pure O works for me because I don’t have any compulsions.”
By the way, a lot of people have Pure O, will fully admit they have compulsions, but some
people maybe if they’re new to it will be like,
“No, I don’t have any compulsions.”
And what you’ve said there is they’re not separating the difference between obsession and rumination. Rumination is a compulsion. Rumination is the overthinking.
So an intrusive thought is something that pops into your head. You can’t do anything about that. None of us here or anyone listening has any control over the thoughts that come into our head, which is why we shouldn’t beat ourselves up if we have a weird thought, scary thought, taboo thought, because we haven’t decided to have that thought, right? But, if we then get fixated on that thought and we start overthinking it, thinking about it, analysing it, reviewing it, all of that is rumination and rumination is a compulsion. But people, some people don’t quite separate the difference between intrusive thought, obsession and rumination.
E: Yeah, they’re seeing rumination as part of the obsession, of part of the obsessing, rather than seeing it as a compulsion.
W: Yeah, they’re just seeing it all as thought
W: and not thought can also be compulsion. So rumination is something anyone that does it, is doing. It’s not an automatic process. It’s somewhat unconscious in that it’s happening but they can become aware of it and then control it which is what we do in therapy. We find different ways.
But yeah with the intrusive thought that comes into your head nothing any of us can do about that. It’s an automatic thought. It’s out of our control and we shouldn’t judge ourselves for having automatic thoughts. You know it’s just our brain being weirdly creative. We all have those thoughts whether we have OCD or not. We all have taboo scary weird thoughts from time to time. But yeah, the rumination is something we’re doing and that’s what we need to work on.
W: Okay, let’s go to a short break.
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W: I also wonder to what extent the potency of the mental compulsion is exacerbated by the fact that we are on the same turf in the mind as the initial obsession, whether the stakes are higher. And what I mean by that is, a compulsion that is mental and purely internal could get out of control and become an obsession again. It could actually lead back to the original intrusive thought because it isn’t externalised and because there is that greater smudging. And so one thing I have wondered is whether, another reason why Pure O has been taken onboard by so many people as a badge really, to explain their own experiences is because it recognises that actually internal compulsions can be as bad as if not worse than externalised compulsions. And that when we’ve been in an environment, a media environment and a societal environment where the only thing that ever has been talked about for so many years or known about in, in inverted commas, for so many years, is the externalised compulsions, like, have to touch some things so many times, etc. I guess the Pure O conversation is an opportunity for people to have those internalised potent compulsions recognised equally as well.
S: Yeah, I think, like, for me, you know, when I was really struggling in my mid-twenties, I mean, I had physical compulsions as well, but I did a lot of mental compulsions. Pretty much everyone would do mental compulsions as well as physical, right? Even if your contamination and you’re a hand washer or a shower, you’re probably also stuck in your head a lot of the day, so therefore you’re doing mental compulsions too. But I remember sitting at my desk when I had an office job and just most of the day I was almost zoned out, just ruminating in my head. And it, you know, I wouldn’t think that I was wasting a lot of my day doing that, whereas if I was clearly stuck at the, the basin washing my hands for four hours it would be a much more obvious problem to me because it’s much more clear cut. And that’s the issue of mental compulsions. We don’t often see that people, they could be living their life, you know, at work, but actually they’re not really at work, they’re in their head. It’s as bad as being stuck at the basin. Well, maybe not as bad because at least they’re able to get paid for showing up at their job, but they’re not really present. But you know, going on to the issue, am I right to talk about maybe one of the issues of Pure O.
E: Yeah, please do.
W: I mean, look, I am for the term because it’s helped so many people. I’m not against it. I’m very… anything that helps someone, I’m open for it. I just think people need to be aware that there’s always compulsions. They’re just in the head. So that’s where purely obsessional just is a bit… a poor choice of words, whoever, well, maybe Steve Phillips or somebody coined it. And I’m a big fan of his, so I’ll insult him. But, you know, it needed to be created because people needed that help at that time. So I’m fully on board with it. And I’ve had this conversation with him because I said to him in one of my episodes in an ideal world, Pure O wouldn’t exist as a term because it’s OCD. It’s as simple as that. Contaminant, but therefore contamination, OCD, relationship, OCD, religious OCD, harm, OCD goes on. None of those would exist either because none of them are real. It’s all OCD. The only term that would exist is OCD. But as humans, we want to find tribes and we want to find understanding and we want to find resources, people talking about contamination in OCD, so therefore we’ve adopted these terms. And also it helps with researched and things like that. But in an ideal world, it’s the process behind the theme is what we’re tackling in therapy. There are some nuances with themes, but generally it’s the thing itself, the OCD. So in an ideal world, in my opinion, none of these would exist, but for the time being, they are useful and we need them.
Where I will add a bit more criticism to it is even if we stick with the purely obsessional means there’s mental compulsions only, that’s not really entirely true. And I’m not going to say that’s not true for anyone in this world. I’ve not really seen that in my practice. There’s always physical compulsions. So often people are mainly doing mental compulsions, but then they’ll say, oh yeah, but I asked my partner for reassurance 20 times a day. In my mind, that’s a physical compulsion, not a mental one, ’cause you’re doing something physical with your mouth, you know. Checking Google, going on, looking for reassurance on Google is a physical compulsion. Scanning, if you’ve got relationship OCD and you’re looking at your partner suspiciously to see if they’re attractive today in your mind or if they’re doing certain things that make you anxious, that’s hyper, threat monitoring. You’re being hyper-vigilant, that is a physical action. And people often discount these as physical compulsions. So even with Pure O, most Pure O people are doing physical compulsions. They just either may not realise it or they may not think that they’re physical compulsions. So even when we take that, there’s really no such thing as Pure O. So again, the term needs to exist and for now, but it’s really not true in many ways because we’re always, you know, I wrote a list earlier like or last night that I’m missing some, avoidance. If you avoid things, it’s technically a physical compulsion. Most people, if they’re worried about abusing their kid, they might start avoiding their kid, not wanting to change the nappy. That’s a physical compulsion. Googling, reading body language, checking, asking for reassurance, confessing, all of this is physical compulsion. So yeah, people with Pure O, I think, are doing way more physical compulsions than they realise. It’s just probably because they’re stuck in their head most of the time that that term really sits well with them. And that’s why the term’s fine, but it’s just a highlight. And I think it’s worth highlighting, ’cause if anyone has Pure O, they listen to this, to be alert to what physical compulsions might they be doing that they’re not aware of, that they can cut out. Cutting out the mental, that’s gonna help. But if they’re still doing compulsions in any form, it’s gonna keep them stuck. So that’s just worth highlighting.
W: But again, pro the term, but it’s got issues.
E: I’m often quite resistant to, can over-reliance on labels and diagnostic labels and hearing you both talk about Pure O and the way in which it’s used. So like I would worry the attachment to Pure O as opposed to OCD is inadvertently and without meaning to then putting more stigma on OCD.One side of the coin is that you, it can almost be shorthand to describe your experiences in a way that other people can pick up on and you can have some shared experience. But then the flip side is it becomes like a reliant as part of your identity. And then that could cause more problems if you start, having experiences that are outside of what you’ve decided is that narrow definition.
S: Yeah, like if I do an episode on a particular theme, I try and avoid the themes where I can, but I have covered episodes on the themes. Yeah, if I do an episode on relationship OCD and I don’t talk about someone obsessing that their partner might cheat on them, and it’s like an OCD obsession versus a genuine worry there are cause for concern, and that doesn’t come up, someone might say, might get really triggered that that wasn’t mentioned therefore do I have a relationship OCD and they go in that spiral and then they’ve got OCD about OCD which is a whole different theme of OCD, but no, you’re right and like the DSM – Diagnostical, Diagnostic Statistical Manual Mental Disorders or Diseases and then the ICD International Classification of Diseases or Disorders I get confused which is like the European version of the DSM they, in all of the, they have these neat little lines on how to separate what psychosis is, what OCD is, what generalised anxiety is, what depression is.
The brain doesn’t work like that. It’s a mash-up of neurons in our head, firing and wiring. It doesn’t have these neat boxes, but as humans we have to create neat boxes so then we can research and study and diagnose, which we need to, and diagnosis is useful, but it’s not perfect.
So it’s again, what I was saying earlier about trying to categorise OCD, we almost need to, like Bruce Lee said, be water, you know, be a bit more fluid. Again for someone with OCD, if they’re really triggered, they want that certainty. They want that reliance and stability and safety and a label. And I understand that I’ve been there myself.
But when you want that rigidity, when that rigidity doesn’t play in your favour, it will trigger you. You know, like I said about the episode, if they listen to it, it doesn’t cover a particular feature, it might trigger them. So an over-reliance on the labels might backfire as well. So it’s almost that’s why I think it’s better to have a reliance on just OCD as opposed to the themes. And I have seen people say I don’t have OCD, I have Pure O, I’m like no it’s OCD. It’s just, you know, you don’t have contamination OCD, but you have OCD. I’m not pedantic like that with my clients, I’m just using this to teach. It’s really just the OCD.
W: What do you think is the best way of treating OCD compulsions where the person that comes to you is preoccupied particularly by the mental compulsions that they have?
S: Yeah so exposure and response prevention therapy is the most researched therapy for OCD, which is effectively triggering yourself for the sole reason that you can respond differently which is i.e. not doing the compulsion. So, worried about contamination, it might be touching the door handle, which is the trigger, the exposure, then the response prevention is that I’m not going to wash my hands. Or I’m going to wait until there’s a normal time to wash my hands, like I’m about to eat dinner. That’s when I wash my hands. And you’re giving yourself long enough that your brain learns new information that the door handle was probably okay. Or that it was a faulty signal. That’s ERP. So, ERP will still work for mental compulsions. It’s a bit harder with mental compulsions because you’re, it’s not saying it’s emotionally hard to sit here and not wash your hands, equally easier because I know if I’m actually washing my hands or not.
Whereas with rumination if we’re sitting here I could easily slip into mental rumination, mental
compulsion without even realising it. So that’s where you ideally you need, I mean ERP alone can still help but if you can bolt in say Acceptance Commitment Therapy that can help you work with mental compulsions. So ACT for short, it’s about psychological flexibility, basically becoming more flexible so we don’t break. If we think of like a physical leg, if we don’t stretch we might tear a muscle. So kind of like stretching for the brain to make sure we’re more bendy, more flexible and less likely to tear something. Not literally but figuratively. So there are many skills, like one I use a lot with clients is called Dropping Anchor. You can find that online, like how-to guides free audio on how to do it is created by Dr Russ Harris. But it’s basically learning to notice and name your thoughts, like I’m having a thought right now that something might be contaminated. And we’re trying to, that gives us a bit of distance from our thoughts and we call that diffusion enact as opposed to fusion, connected, hooked. So we want to unhook from the thoughts, connect with your body, remind yourself that you’re in your in a body, often when we’re anxious, we feel quite trapped and like we can’t move and it’s like no I still have a body I can still move it and then we use our senses which is reminding us that we’re in a room we can choose what we do with this body in this room basically take the blinkers off when we’re anxious it feels like tunnel vision and remind us actually there’s so much more going on that’s also grounding us into the present moment so there are many skills in ACT that teach that kind of thing so if one of my client starts ruminating, I’ll pick it up. They glaze over, they look distant, I’ll say,
“Are you ruminating?”
They might say,
“Right, let’s just drop anchor quickly.”
And then after dropping anchor,
“Right, let’s engage in a conversation. Tell me about school, whatever’s going on.”
And I’m not distracting them. I’m trying to engage them in their life because that’s what I want them doing day to day. Then as they’re engaging in their life and grounded, what they’re not doing is ruminating and therefore they’re weakening the OCD cycle. So there’s many ACT skills and then the other part of ACT is knowing what matters to you or your values and taking committed action.
So once we’ve grounded them a bit, pulled them out of their head, it’s encouraging them to go and live their life and live their life even if they’ve got thoughts and feelings that are uncomfortable. Because often the feeling is I can’t live my life until I’ve got rid of these thoughts and feelings and that’s wrong. You can do whatever you want and you can bring them with you, it’s just uncomfortable. So it’s learning to tolerate and make space, as another word in ACT, make space for these uncomfortable thoughts and feelings. And noticing and naming the urges to compulse and bring yourself back to the present moment. And there’s all skills that teach that. And then there’s also Inference-based Cognitive Behavioural Therapy or ICBT. It’s not a therapy I use, but it’s growing in popularity and research, which might be another alternative.
W: I really like the mixed approach that you talk about there. Judging from the name of the new centre that you’ve co-founded, it seems that’s the approach you take there as well, that integrated approach to approaching OCD.
S: Yeah, we bring exactly that. We bring in, you know, Johnny, our founder and I, we both trained integratively, and we’re just bringing in different therapies and trying to find the right balance. We also use Compassion Focused Therapy a lot, which is trying to deal with inner critic or even the shame of having these thoughts in OCD and trying to bring a more compassionate voice in and make that compassionate voice louder to deal with that.
W: Thank you so much for coming on the show again Stuart, it’s been great talking to you.
S: It always, been my pleasure.
W: Yeah, thank you so much, it’s been fascinating.
S: Yeah, thanks for having me.
E: Thanks so much everyone for listening and please tune in again in two weeks time for
another episode of Lively Minds, the Mental Health Podcast.
W: Please note that this show does not constitute medical advice and is not a replacement for seeking professional help. You can find signposts into support on our website anyamedia.net/Livelyminds
E: Make sure that you keep up to date with our shows by subscribing wherever you get your podcasts and find us on social media @Liveminespod.
W: Take care and bye for now.