← The OCD Stories
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- [00:00]
Stuart Ralph
You're listening to the OCD Stories podcast hosted by me, Stuart Ralph. The OCD Stories is a podcast dedicated to raising awareness and understanding around obsessive compulsive symptoms. I do this through interviewing inspired therapists, psychologists and people who have experienced OCD. Welcome to the OCD stories and welcome.
- [00:22]
Podcast Announcer
To episode 518 of the podcast. And in this one Jonny and I practice some acceptance commitment therapy skills together. So it's kind of a JO podcast. Jonny is a UK based therapist and co director at the Integrative center for OCD Therapy. In January, Jonny and I are running an ACT skills training for therapists. So I'll put a link in the show notes if you want to check that out if you are a therapist. But as we were planning for this episode before, actually a couple of skills would be really good to cover for the listeners on my podcast.
- [00:55]
Stuart Ralph
So here it is.
- [00:56]
Podcast Announcer
And in particular we talk about the skill dropping anchorage, how the skill dipping in and out of the Stream can help us learn how to deal with rumination. Jonny and I role play a client session using Dipping in and out of the stream and much more. So hopefully the role plays sort of a new addition to the podcast. Hopefully that's interesting. But yeah, these skills are important to Jonny and I in our therapeutic work and we hope they help you in some way. And thanks to our podcast partners.
- [01:22]
Stuart Ralph
Nocd.
- [01:23]
Podcast Announcer
If OCD is interfering with your life, NOCD can help their licensed therapists specialize in exposure and response prevention therapy. The most proven therapy for OCD with an OCD effective treatment that is 100% virtual is available for children and adults with OCD and most members can get started within seven days on average. No hassle, just real science backed help and support between sessions. Begin your journey@nocd.com or I'll put the link in the episode description. So thank you so much to Jonny for his time and of course thank you to you guys for listening. As always, it means a lot. Without further ado, here is Jonny and myself, Stuart.
- [02:03]
Stuart Ralph
Welcome to the show Jonny.
- [02:05]
Jonny
Thanks Stu. And I just wanted to say up front how moved I was by the 10 year anniversary episode. It was so powerful. So anyone who contributed that's listening. It was so moving to hear what people said and I loved hearing some of your friends as well in there Stu. Just saying like how much you have given to this project and how persistent and dedicated but also how you've just put your whole self into it for so long and grown through that process. So that moved me as well.
- [02:44]
Stuart Ralph
Yeah, no I appreciate that. And like you said, thanks to everyone that recorded and the couple friends I had on there. Yeah, it was nice to hear them say that, but, yeah, their responses were really tame. I thought they were going to be way more effective. Yeah.
- [02:59]
Jonny
Yeah. I'm not used to them being so nice about it.
- [03:04]
Stuart Ralph
But. No, it was nice to hear them say that. And in one of them in particular, I lived with him for. Did I? No, I think we had just moved out. I was living with him for a few years prior to that. But he saw the things that led up to the podcast, which I think he alluded to, and me trialing different things. And I had a podcast before the OCD stories around marketing. And so that's where I learned the skill of podcasting. And. Yeah, so you saw me working hard on that and. And everything led to this point. So. Yeah, there was no. No wasted time. Well, there was, but not, not, not a good way.
- [03:41]
Jonny
Cool.
- [03:42]
Stuart Ralph
No, thank you. So, yeah, today we are doing, actually in January, we're doing a training for therapists where we're going to cover acceptance of commitment therapy skills that we use in therapy for ocd. And then we thought as part of that, it would be cool just to cover one of those skills. Well, an intro. And then the main skill we'll cover, we'll do a role play for people who experience OCD so they can see what it's like. And many of them listening probably do this with their therapists. And if not, it's another tool to bolt into the mix. In the show notes, I will link to people like Russ Harris and Obviously, Johnny, your YouTube channel, where you've recorded a load of guided act skills if people want to practice and investigate further. But just before we get into the role play, I'll talk about dropping anchor, which is one of the sort of foundational skills of act, at least in the way Russ Harris practice practices act. It's a skill we both use and teach pretty early on, I assume, view of every client you work with.
- [04:48]
Jonny
Yeah, yeah.
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Often first session.
- [04:50]
Stuart Ralph
Yeah.
- [04:51]
Jonny
Or second session.
- [04:52]
Stuart Ralph
Yeah, absolutely. And I will adapt it for younger kids, which I might, if I remember, I'll talk about that. Yeah. But if not, you can adapt it for a younger audience. Be a dropping anchor, just to keep it brief, because we want to get into the skill. Dropping anchor. The acronym dropping, not the acronym, sorry. The story behind dropping anchor, or the metaphor is that if you're a sailor and you come into shore, for example, and you can't dock, you drop an anchor unless there's a mooring ball. But yeah, you drop an anchor and that keeps the boat, obviously it swings on the anchor, but it doesn't go further than the furthest line of the, the anchor rope. And that stops the boat getting smashed into the rocks or dragged out to sea if a kind of swell or storm comes in. And much like an emotional storm, that can carry us away. And for me, I always say to my clients, us getting carried away is us doing a compulsion or maybe if we're angry, it's us shouting at someone or slamming a door or something that might actually make our situation worse. And in ocd, doing a compulsion will make our severity worse in simplistic terms. So, yeah, before I get into the acronym, have I set the metaphor up well enough, do you think?
- [06:11]
Jonny
Yeah, I think you have. And I think it's important to say that the reason ACT emphasizes metaphor, as does CBT and as does other evidence based therapies, is that there is this research that metaphors will stay with people more than detailed theory. So they did these studies where people will remember metaphors 10 years down the line, whereas they can't recount any of the, the sort of theoretical learning, you know, unless you work at it and learn it and memorize it like, you know, like school. Whereas a metaphor will just stick with people. So that's one of the reasons I like it so much. And when I was working in the nhs, I would sometimes work with clients that had done CBT before and I would ask them, you know, what do they remember? And quite a few times people say, I don't really remember a lot of what I did, but I do remember dropping anchor. And they would literally be saying that. So I did have quite a few times where I've, I've worked with people that it just sticks in people's minds. So I think, you know, there's lots of micro short tools within acceptance and commitment therapy and dropping anchor is just one of them. But I like it because it has the metaphor encapsulated, you know, within it and it really, it just sticks with people. So, yeah, no, I think you set it up really well. And yeah, we're gonna, we're gonna talk about some of the nuance to it, but we obviously won't cover too much.
- [07:41]
Today because we want to get into the practice side.
- [07:45]
Stuart Ralph
Yeah, yeah, good points. So the acronym for dropping anchor is ACE A C E. So acknowledge your thoughts and feelings. Or sometimes I will call that notice and name, which I know you do too, Johnny. I just find notice the name a Simpler thing but yeah. In short, acknowledge your thoughts and feelings. Connect with your body. No yeah, connect with your body. I got it correct. So basically move your body. Notice what it feels like. You know, really be in your body as your muscles stretch or bend and. And notice that and then e. Engage with the world around you or engage with your senses. So what can I see? Smell, touch, taste here. So A for me is very much like we're trying to get some distance or enact diffusion they call it. There's a whole exercise here with your hand on your face. But we won't be able to go through it without you need a visual video. So but yeah we if we can learn to see our thoughts as just thoughts. So instead of being like cliche example but I'm looking at a door handle. That door handle is contaminated. If I was worried about contamination on the door handle, I go that door handle. If I'm really fused of it, the door handle is contaminated reservoir I can go no the. My brain is telling me that the door handle is contaminated. Or there's that story again that the door handle is contaminated. If we can name the process of what's actually happening, we get to the truth which is it's a thought, it's a feeling that is happening versus we buy into the story which is the door handle is contaminated. And at that point we get pulled in the we then going to compulse. So that's that kind of. And then also you do it with your feelings, noticing what you're feeling. You could do a brief body scan. Just notice where in your body you feel it. And then you could bring in some acceptance. Can I allow it to be here? Can I let this feeling be here without acting on it as a little bit of urge surfing which is another act skill which we won't cover today. And then connect with your body is like I said, moving your body but just really noticing being mindful of your body. That's anchoring you in the here and now. It's also reminding. Reminding you that you're in the world and you. You control this body. You can do what you want with it. I. When I've been anxious a lot over the years, it's felt like I. I can't move. I just have to sit here and actually moving your body and connective it reminds you doesn't matter how anxious you are, you can still move your left foot and your right foot and your left arm, your right arm or whatever. And then lastly engage with your senses or the world around you. So what can I see, smell, touch, taste? Here you could do 5, 4, 3, 2, 1. For five things I can see, four things I can touch, et cetera, et cetera. I don't do that personally because especially when you're in the downstairs brain, you're overwhelmed. I can't remember what order or what. What number. So I'll just pick any random number. Okay, three things I can see, two things I can touch, two things I can smell, two things I can hear. Maybe one thing I can taste. Or I'll skip taste. And what I often say to my clients is, as you do that, don't just go. If you're doing site, don't just go. Door, tree, doll's house. So chair, pillow, because you could be super anxious and reel that off. Instead, I go try and notice a detail because it anchors you more in your upstairs brain. So, okay, door. What do I notice about the door? It's actually a bit uneven, and it's got a silver handle to it. My Christmas tree in front of me, it's got little stitched mushrooms on it and little gold baubles. Okay. The chair, it's green, and it's. It's a particular material, so it looks like it's patchy that it's not, and that I have to really focus on that detail, which, again, is pulling me out of my head, stopping me ruminating. So it's interrupting that process, and then it's also reminding me that I'm in the world. Because for me, sometimes when you're anxious or any kind of obsessional focus, you just get this focus. It's like tunnel vision, and you almost lose sight of everything else. And I think using your senses is like the horses when they go down the road and they have those eye patches, which I assume limits to, so they don't see the cars and get startled. I'll have to Google this before I publish it, but I think that's the case. And it's like taking those blinkers off, which maybe not really a good thing for the horse in that scenario, but for us, allows us to see everything that's happening in the world. And then we can decide, do I want to keep focusing on all this stuff and compulsions and rumination, or do I want to go do something in alignment with my values? And then at the end of dropping anchorage, it's always, take action. Focus back in on what you're already doing. If you weren't doing anything, go do something that matters to you and keep making space for the thoughts and feelings Take a breath. So yeah. Johnny, thoughts on that?
- [12:39]
Jonny
Yeah, I think that's great. I just wanted to add, I see it as a progression as well. So this sort of stage one where we really follow those steps in depth so we might notice a name our thoughts, notice and name our feelings, urges, sensations, impulses, you know, whatever's showing up with ocd. Then we're getting into the body in an active way. And then like you said, we're maybe doing some engagement style tasks. But what we want to do with drop and anchor over time is progress that. So the first progression is we might just shorten the whole process down so we can do it in much quicker time period so we can use it in, in the heat of the moment when we're triggered. Then you might let go of the middle stage, the body, so you're doing more just the acknowledging and the engaging part of dropping anchor. And then finally we might let go of all the scaffolding and really we're just engaged in the present moment. We're just using the acknowledging or the noticing, noticing name skills as we get pulled into mental compulsions or as we start to struggle with our feel things. So it's important to see it because some people would look at it and go, well, that sounds like a grounding exercise. And you don't do grounding with ocd. That could be compulsive, but it's like we're missing the depth of it by looking at it like that. Like you're starting with the full run through of all the scaffolding. That's helpful when someone's in high distress, high rumination, they can't just stop ruminating. They can't just sit with feelings, they can't surf an urge to do compulsion. They need a sort of scaffolding and a bigger intervention to start to break, sort of circuit break that OCD behavior. But then over time we condense it, we simplify until really we are doing the allow an intrusive thought to come and go, no compulsions, and taking action aligned with our values. So people will say, well, you know, isn't the coming back to your body compulsive? Well, anything can be compulsive, right, Depending on the function. So you can go to therapy for compulsive reasons, you can do ERP for compulsive reasons. If we're doing it to solve the uncertainty, control distress, try to prevent harm. You know, anything can be done as a compulsion. And so the key with dropping anchor is we're not trying to get rid of intrusive thoughts. We're not trying to control emotions. We're trying to let go of compulsions, get our attention under our control and our actions under our control so that we can move towards values rather than towards ocd. And so it's all about the function. So, you know, the body. Yes, the body could be done compulsively if someone has sort of repetitive behaviors or they have more. More the sort of ritualistic type stuff. Yeah, you have to be careful. People aren't sticking in a compulsive body movement. Certainly people can try to use acknowledging to control their thoughts, to suppress or push it away. So you have to cover that. And the engage could be done as a distraction. So you have to cover that and make sure people aren't trying to distract. They're trying to, as you so well put, get engaged in the world in front of them rather than their compulsive rumination. And we see your lovely cat jumping up, up to you as a sort of visual metaphor of being in the present moment, engaged in something you value. So, you know, it's like you have to make sure dropping anchor isn't seen as this sort of control strategy. You know, we're trying to regulate distress and get OCD symptoms down by grounding and, you know, we're not doing that. You know, it's a tool to help us let go of compulsions, accept distressing, intrusive thoughts, images, sensations, emotions, impulses, and, you know, to be able to engage in life in a meaningful way. So I always think it's important for us. Like some people criticize act with a kind of straw man argument of, oh, that sounds like you don't need to do all of that. Or it's compulsive, but it's like you're missing that. We move through stages to, to simplify this. So that, that would be a big one for me is like, you know, dropping anchor is just one way of doing this. Steve Hayes has other short, you know, short act practices, as do lots of other people. Patricia Zarita Ono, you've had on the podcast, has her short micro practices. Lots of people doing ACT. Mike2hig has some in his book, so there's lots of ways of doing it. I just personally like dropping anchor because it sticks in people's minds and it's super simple. And, you know, Russ is, in my mind, one of the best at just simplifying things. And, you know, I also have a lot of allegiance to Ruska's, really his. His work got me out of My OCD more than anything else, you know, so I feel a great debt and sort of allegiance to Russ because, you know, that was what really helped me the most. Along with exposure. Right. It was. Combining act with exposure was the most helpful thing to me. So, you know, I like dropping anchor for that reason.
- [18:15]
Stuart Ralph
Yeah. Yeah, I agree. I integrate dropping anchor with exposure a lot, as, you know, as you do. Um, yeah, I think you're right. I think what I say to my clients is we practice it in its entirety, and then for the first week after we've learned it, I want you to go away, listen to maybe one of Russ's guided audios, or I sometimes give him your videos, or I'll say, here's a PDF. You know, just once a day when you're calm or not too overwhelmed, just practice it in the same way. Sticking with a metaphor. We don't learn to sail in rough seas. You know, we learn to sail where there's just a bit of wind. I assume I'm talking like a sail.
- [18:53]
Jonny
But I think let's just go with the assumption that we understand sailing and we'll share this metaphor. I'm sure plenty of sailors could pick apart how we're using this metaphor, but, yeah, I think we get what you're saying.
- [19:08]
Stuart Ralph
Exactly. And where was I going with that? Yeah. So I. I say, right, just once a day, I want you to practice it in its entirety because I want you to learn the whole of it. And then once you know it off by heart, you can freestyle with it, which is what you're saying, the progressions. And now if something triggers me, even if it's not ocd, but I'm just overthinking, I'm ruminating on something, maybe something I said and I feel like an idiot or whatever it is, I'll use dropping ankle variations of it to let it go. And I might just be simply naming it. There's that story again about me being an idiot. Okay. Maybe just come back, notice one of my senses. Right. Refocus. Or just name it refocus. Or I might just go, okay, just use my senses and then refocus. So I, like, really shorten it.
- [19:56]
Jonny
Yeah, exactly, exactly. But that takes time. Like you say you want to learn it in its entirety. Get to a place where you can really implement that during times of distress. And then you start to simplify, shorten, you know, crunch it down.
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Stuart Ralph
Yeah.
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Jonny
Until, you know, the most of the way. I. Yeah, I. I almost never do a full run through dropping anchor. You know, I'm always Just acknowledging and engaging, you know, and often I'm just engaging and I'm only using my skills. As my mind pulls me into rumination or, you know, I sense a struggle with an emotion or something, then I'm using those skills. But that took me a long time to build to doing that and I would have no hesitation to go back down that framework. If I felt myself getting really tangled up with something or, you know, whatever it is, then I might well be doing a 5 to 10 minute long dropping anchor. And, and, but you need these, you need these skills to be able to be done very micro short time period. Because in life you can't extract yourself from a situation and go, okay, I'm going to do a long drop in anchor. You have to be able to do a very brief. Just notice my thoughts and that my mind's trying to go off into mental compulsions. Notice that I've got a wave of anxiety or shame or disgust or another emotion. Acknowledge that and then refocus. You have to be able to do that in 5 seconds, 10 seconds to be able to do that repeatedly as you face difficult intrusive thoughts and feelings in your life where you can't just break off and go and practice. Often you have responsibilities, you have things you're engaged in that you can't just walk away from. So yeah, I think it's all about how do you, you, how do you sort of crunch it down and make.
- [21:43]
It really responsive and flexible and you.
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Stuart Ralph
Can bring in other elements as well, like self compassion, breath work if that's not triggering for you. And when I say breath values.
- [21:54]
Jonny
Values. Reflection.
- [21:56]
Stuart Ralph
Yeah, exactly. Spot on. Cool. So now we're going to talk about dipping in and out the stream, which is a really useful exercise for working on handling rumination and, and learning how to unhook or defuse from our, our thoughts and when we get pulled into rumination. So why don't you explain that to the listeners? But we're going to role play. So we'll get in the role play now. So you almost take me through it as your client and then hopefully that will be probably the best way for the listeners to pick out.
- [22:28]
Jonny
Do you think you mean role play it first and then describe what we've done afterwards, or do you want me to introduce it?
- [22:35]
Stuart Ralph
Set it up to me as if you would a client who's never done dipping in the stream?
- [22:41]
Jonny
Yeah, sure. And then we can talk a bit about it afterwards and things. Yeah, sure. So, yeah, we're going to assume that we've worked Together for a little while. You know, we're not going to go straight into this. I don't do this practice with people who are in sort of constant rumination and don't have any diffusion skill yet. You have to have some ability to diffuse from baseline rumination before you sort of do this. But let's assume we've worked together for a little while. We've got, you know, all the steps that you would go through in one to one therapy and we've got some skills in place. And then now we're going to target the mental compulsions directly. So yes, Stu, one thing I wanted to cover today was a skill that I think is particularly helpful for practicing how to unhook from mental compulsions. We've talked about mental compulsions. These internal processes of rumination, analysis, testing, checking, worrying, self, reassuring. All these mental processes we can do in response to harm ocd, which you've shared with me, which is your theme that we're working on. This is a tool where we only ever will tell you to do compulsions on purpose in this tool. Everywhere else we're trying to reduce them, disengage. But for this practice we do a short period of the mental compulsions, like 10, 20 seconds, 30 seconds max, to sort of get caught up in that process. Then we use the drop in anchor skill that we've been practicing so far in therapy to step back, to get out of that thought loop and then we rotate back and forth number of times to get really good at. I'm caught up in mental rumination now. I'm stepping back, I'm detached, I can focus on things I value. And then we're back into it again. And we go back and forth, back and forth. And the metaphor is dipping in and out of a stream. So the compulsions of the stream, we're getting caught in that stream. Often it's a river, right? It drags us along. We're trying to then step onto the.
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Riverbank with our drop in anchor skills.
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Does that, does that all make sense?
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Stuart Ralph
Yeah, it does. It does, yeah. No, it does.
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Jonny
I think it'll make more sense as we practice it. It's one of these skills that until we do it, it all sounds quite abstract. So with, with clients, I'll often start on easier thought loops. So we'll start on everyday rumination about worries and concerns. Non OCD related content. We're going to go into OCD because we've been practicing diffusion a lot. I think you've got some degree to implement diffusion. I think we're ready to now do it on mental compulsions, but at another time we'll explore doing it with worry.
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And stress and self criticism and other thought loops.
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So we're going to work with your harm ocd. So we want to think about over the last week, what kinds of mental compulsions you've gotten caught in. So if you think back over the last week when you, you've seen your mind go into these mental compulsions, this rumination, what have been the, the main compulsions there? Has it been worry, has it been self reassurance? Has it been testing, check in. What would you say you've noticed your mind doing?
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Stuart Ralph
Yeah, rumination generally, but more looking for like evidence that I haven't done something bad or haven't hurt anyone on my travels. This, this week.
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Jonny
So like mental reviews. So like reviewing.
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Stuart Ralph
Yeah, replaying, almost examining those, those experiences, those memories, sometimes reassuring myself that I would never do anything like that I'm a good person and just, I get pulled in for what feels like hours.
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Jonny
Yeah, yeah, yeah. So, yeah, so there's a lot of mental review, there's a lot of self reassurance. There's probably other mental compulsions. That's work with those for now. So what I'll do is I'll demo it out loud. I won't get you to do it out loud, but let's imagine, you know, I'm doing the practice as you gonna sort of verbalize it and then do a little bit of drop in anchor to show you. So yeah, so I might say to myself, okay, this week I was traveling. I went past that vulnerable person, that elderly person, you know, is there a chance that I could have pushed them? Did I do that? I don't think I did. I don't think I would do that. You know, I'm sure I wouldn't have done that. But what if I did?
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Okay, drop anchor.
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Acknowledge my thoughts and feelings.
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So I notice what my mind does.
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So let go of that active rumination.
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And observe the automatic thoughts and notice images as well. And I notice what I'm feeling in my body. Maybe anxiety, maybe something else.
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Get into my body briefly and then.
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I engage with the world around me.
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And then I go again, you know, so I might say I wouldn't have.
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Done that, but what if I did? I better go over that memory again. Right. I'm playing that memory in my mind.
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So you see what I, what I'm doing. I'm sort of getting caught in the compulsion. Obviously there'll be more specific details for you. It'll reflect your internal processes. But let's run through, I'll guide you through now and that's what I'd like you to do. You don't need to do it out loud, you're doing those compulsions in your head and just follow the guidance. We'll do a little bit of connecting with motivation to start and then we'll go into it. So, yeah, sitting in a comfortable, grounded, stable posture and taking a moment to connect with your values statement. So we've developed this value statement that, that has the important people in your life, your core values, your goals. So just think about that for a.
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Moment, try to connect with it. Picture those people, say those statements of the person you want to be in response to ocd.
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What does that mean? In action? And also we'll connect to workability. So workability tells you that responding with these mental compulsions for hours isn't getting this clearer in your head, it's actually.
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Confusing you more and it's pulling you more into ocd.
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So just connect with the fact that.
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The mental compulsions aren't working to take you towards values. So you want to try something different.
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And then from that place of your values and your workability, start to activate that rumination.
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So the mental review, the self reassurance, get caught up in that for about 20 seconds.
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And then drop anchor.
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So acknowledge your thoughts first of all. So notice and name your thoughts. You could notice a name, worry, you could notice a name analysis, mental review, self reassurance. And then acknowledge what you're feeling in your body, your head, your chest, your abdomen. Notice and name it. Anxiety, dread, doubt, confusion, shame, something else. And then get into your body.
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Any.
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Way you like, some movement. And then engage with the world around you. So notice where you are, what you're doing, notice what I'm saying. But also engage with the world around you, notice the details.
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And in life you would be refocusing.
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On action, so you'd be refocusing on.
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Whatever you care about in that moment.
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Whatever you're doing that matters to you. But here, just engaging with the world around you.
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And we're going to cycle through all of that again.
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So get caught up in those mental compulsions. And then drop anchor again, notice and name your thoughts.
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Try to gently step back and just.
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Observe you're in a monologue, any images, notice where you experience that in your head. So get a spatial location of your thoughts, helps you diffuse. And then notice what you're feeling as well. And this time we'll move to just engaging. So Then engage with the world around you.
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So as you progress dropping Anki, you don't have to come back to the body. You can just engage.
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Notice where you are, what you're doing. This moment.
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Podcast Announcer
Now.
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Jonny
You and I here practicing these skills together.
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We spend a bit longer in the engage phase.
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So it could be 20 seconds in.
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The rumination, and then 30 seconds longer engaging. And then one more time, get caught.
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In the rumination loop. And then again, drop an anchor. Acknowledge your thoughts, acknowledge your feelings, sensations, impulses, anything showing up in the. Urge to do a compulsion. And then engage with the world around you and what you value in this moment, what you want your life to be about.
- [34:36]
Podcast Announcer
Good.
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Jonny
So I'm interested what you noticed as.
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You went through those different stages. What showed up?
- [34:46]
Stuart Ralph
Yeah, first I found it hard to let go. It did get definitely easier by the last round. I wouldn't say it made me calm, But I was. There were moments where I was able to really engage in what we were doing and temporarily let go of what I was ruminating on.
- [35:12]
Jonny
Yeah, great. Fantastic. So that sounds like a really good first run through. This is obviously a skill we have to practice a lot, and then it's a training tool for when rumination shows up in life. So we're practicing it as a, you know, like the drilling a musical instrument. You know, we're practicing scales or chords or something like that in order to get better at that instrument. So we'll need to practice this a lot more. We'll practice it together. We'll use this alongside the ERP we've been doing and the act skills. We use this to target the mental compulsions, but. Sounds like you did really well. Yeah. It won't always make us calm for sure. And that's. We've got to try and do this paradoxical thing where we're not making that the goal. We're trying to get this distance from the intrusive thoughts and this ability to let go of compulsions and then this ability to have a flexible attention that's.
- [36:13]
More under our control even when we're.
- [36:15]
Triggered, and greater acceptance of feelings. So we're trying to basically get better.
- [36:22]
At handling the OCD experience rather than chasing calmness.
- [36:26]
Now, sometimes it might make you calm. You know, life is full of a whole flow of different emotional storms, and we have to be ready for all of it.
- [36:36]
Right.
- [36:36]
But, yeah, really good, good work. Really well done going into this. And we'll practice it more together as.
- [36:44]
The weeks go on.
- [36:46]
Yeah. So. So obviously we're doing and role play yeah, yeah. And role play. So we're. We're doing a quick run through. You know, I'm sure there would be a lot more said, you know, in an actual client session.
- [36:58]
And.
- [37:00]
But you get the. Hopefully the listeners get the idea here. I mean, let me say a little bit about dipping in and out the stream, if that's all right, Stu, and then go from there. So. Yeah. It's a tool that Russ Harris developed in ACT more recently, in the last few years, I think, maybe it might be the last five years or so now, I'm not sure how long, but over the last few years. And he was inspired by the work of Francisco Ruiz, who is an ACT researcher who specifically looks at ACT and ruminate. That's his sort of specialist research area and also metacognitive therapy. So Russ has been very, you know, very much credited that some of the stuff he read about in metacognitive therapy sort of influenced the development. And MCT do use similar protocols. They do similar things of activating the rumination and practicing dipping in and out. They do it with pleasant, pleasant daydreams as well, and other things like that, which you can also do this practice with. I see it as, like. It took me a long time to learn to diffuse. I did many hours of mindfulness practice before I was really able to observe my mind and be able to observe, you know, violent, graphic, distressing, troubling, intrusive thoughts, images, you know, very difficult thoughts to just observe.
- [38:28]
Right.
- [38:28]
It took me a long time to do that. It took me a tremendous amount of time to learn to let go of mental compulsions, to be able to do that skillfully. And I feel like this tool speeds that process up. So for me, you know, I practiced a lot of mindfulness to get there, certainly a lot of ERP using those skills, you know, and to be honest, a lot of practice in the moment being triggered really was the thing that taught me the most. But I feel like this as a shortcut, it's a way of speeding that up. So I didn't train with this myself, but I use it with clients a lot. I practice it with clients a lot. And the way it feels to me is it just feels like, you know, how do we shortcut that process of being able to observe the mind, be able to distinguish obsession from compulsion, to have this flexible attention? It's just a really good tool for all of that. So. And I've had clients. I've had clients that have done lots of ERP and may have benefited quite a bit, but we're still struggling with mental compulsions. And they've said to me that dipping in and out the stream really added something to, you know, they had benefited from erp. The examples I'm thinking of had had positive experiences of great symptom reduction with erp. At the same time they still had a lot of mental compulsion left and going on and they found this tool was very helpful at letting that go. And actually with some people we didn't need that many sessions to do that either. They had developed some diffusion from just doing ERP on its own. But this sort of deepened that. There's a lot of people I wouldn't go straight into this with. A lot of the clients I work with like me when I was at my worst with ocd. It's just constant intrusive thoughts, constant rumination. We can't really from that place start doing it a practice like this because it's just so activated. So for those people, I feel like we need to get our feet underneath ourselves. We need to get some degree of diffusion in life and reduction of compulsions in life and a little bit more of a grounded place to then use this as a training tool. So I don't use this with everyone. I mean, I probably use it with everyone eventually, but not right away for some people. And so you can have situations where if you do it too soon, it actually it activates the mental compulsions too much and a person doesn't have the ability to diffuse and come out of that yet. So you have to, you know, it's best used with clients who have some degree of diffusion already really and some degree of the ability to get out of mental compulsions or their symptoms aren't so intense. For a lot of people I'll start with everyday worry, so I'll get them ruminating about their to do list or even pleasant things things thinking about a holiday or thinking about a hobby or something like that. And you can start with those easier loops, get good with those and then progress into the ocd. So that's a really nice framework. You start with an easy loop when someone can do that fairly well. A moderate stressor when they can do that fairly well. Okay. Then the OCD and then you know that they have the diffusion ability to do it. Yeah. The only other thing I wanted to say on it, you can do it with threat monitoring body sensations as well. So people who are threat monitoring health anxiety symptoms or non concordant arousal in some of the taboo OCD themes, or really there's monitoring of sensations and Our minds and things and lots of OCD presentations, if not all of them. So you can also do it with attention, where you, you put the attention on something, monitor it, and then practice moving into, acknowledging and engaging and allowing this thing to be in the background. So that's a version I do with, with some people who have more sort of somatic body sensation and even, even hyper awareness of thinking and other things like that. And you know, so I'll just address again, people do this whole mindful ruminating thing and criticize an act for that. And this is an old criticism, actually, Metacognitive therapy. If you read Adrian Wells books, he raises that criticism. Many years ago he wrote 10 years, or however old those books are, he was sort of critiquing that. Unless you really get precise on the mental, the kind of active thinking part and letting that go, you could have this scenario where people are just diffusing and they're actually continuing to do mental compulsions. And I don't think that comes from someone who's practiced this a lot because, you know, these mindfulness tools, they have ancient origins. You know, we're obviously not practicing them in any kind of spiritual way or anything like that. But they, you know, they have evolved from kind of Buddhism and stoicism and other places like that. And in Buddhism they talk about papancha as an ancient term which talks about conceptual proliferation. And some people translate it as rumination. It's like in all the ancient Buddhist texts they talk about, you know, mindfulness is to interrupt popuntia. So it's to interrupt how we spin these stories that we ruminate. So really I think you can go directly at the rumination, like metacognitive therapy or rumination focused erp. And for some people, okay, they can do that. For other people that can cause more rumination because there's so much effort to control things and to try and drop and it becomes very much thought suppression very quickly or meta ocd. Am I catching all these ruminations? Whereas what you find with diffusion and tools like this is it's more like the natural side effect of diffusion as we start to let go of the active compulsion. So, so as you get better at observing your mind, you are naturally not adding additional things in. That's why it's called non judgmental awareness. You're not adding that extra judgment. You could say non ruminative awareness would be another way you could phrase that. So I would say act. You get it sort of passively as a result of doing this sort of practice. Well, you just start to, through time, drop the compulsions. That's why people make progress in mindfulness and. And people's minds get better at focusing. And you get, you know, you start with these sorts of practices like me, and you can't focus for 30 seconds, you know, 20 years ago or whenever. It's when I started that stuff, you know, those first sessions, I was ruminating the whole time. Now I can stay very focused for long periods of time. But that took a lot of training and practice. So I think that sort of critique comes from people who haven't practiced it and don't understand that diffusion really enables response prevention. But it's done in a slightly less graspy, controlly sort of way, a slightly more effortless way, which for a lot of people, I think is more helpful. It also accounts for the messiness that we have clients that, you know, it's not as simple as, oh, there's my mental compulsions, now I can just drop them. You know, they have a lot of automatic, you know, very fast minds that are just. Just automatically compulsing, and it's very hard to drop it. And I think diffusion has more usage for that kind of messiness of a human brain in my mind. So. Yeah, I just wanted to say that, because that's a classic area this stuff gets critiqued on. Really.
- [46:21]
Stuart Ralph
Yeah. No fair point. And I think. Yeah, I'll link to Jack's episode. He was one of your clients.
- [46:28]
Jonny
Yeah.
- [46:29]
Stuart Ralph
And he talks a lot about how he practiced the skills between session and was quite dedicated with it. And I think a really good example of developing that muscle over time.
- [46:39]
Jonny
Yeah, yeah.
- [46:41]
Stuart Ralph
A couple other things to add that, like whenever I do dropping anchor with someone or dipping out the stream, I will check in here or there of like, just checking if your mind's wandered off, just come back. Because I know, especially with my young clients, that happens a lot. I'm sure it's the same with adults, but the same as. Yeah, you know, when you do a guided meditation that the guided teacher will go, and if your mind's wandered off, just notice that and bring it back. It's that sort of thing. The other thing I'll add in is just a presentless scale. So like at the end of each round of dipping in that stream, not to 10 with drop in anchor, how present were you? And if you're a five, okay, what do we need to do to get you up to a seven? And we're trying, then, you know. Yeah, I think it's actually okay if they're not a 10 because. Because really what we're looking for is did you catch yourself when your mind wandered off and then did you bring your attention back? Because really, that's the muscle we're training. If you're a 10 continuously, then you're not really bringing your mind back. It's already there.
- [47:45]
Jonny
Yeah, yeah.
- [47:46]
Stuart Ralph
So although 10 is good still, you know what I mean?
- [47:50]
Jonny
Yeah, yeah. It's a refocusing is the key, sort of the muscle. Yeah, yeah. And I do a lot of interactive practice in the beginning and so there I didn't actually ask you much about what was going on. And that's because I like to keep dipping in and out the stream. Quite simple. Because you're really in your rumination. I don't necessarily want to do so much interactive and open up more describing of the symptoms, but. But in introducing the skills and in ERP in the early stages, it'll be totally interactive and I'm doing a lot of, you know, checking in with what's showing up for people and I'm looking for. For resistance. I'm looking for signs that someone is passively doing mental compulsions and not even realizing. I'm looking for dissociation. I'm looking for people becoming overwhelmed and struggling. So interactive practice in my mind is the key and then you gradually reduce that over time. So someone I've worked with for a while, I might be saying very little because they're doing all this stuff and they're working, working these skills. But in the beginning it'll be very interactive and a lot of like, you know, what are you noticing? What's showing up? Yeah, I like the scales as well. And I'll do diffusion scale and acceptance scale as well and things like that.
- [49:12]
Stuart Ralph
Yeah, And I was throwing willingness scale and all of that. So. Yeah. Any other final points you want to add to this?
- [49:21]
Jonny
Well, again, it's a practice, so. So, you know, this is not like something anyone's ever done before. So sometimes people get a little bit confused. They're like, is this what he wants me to do in the moment? Or. And it's like, no, this is a training drill. This is like athletes training a certain move that they're going to do, a certain play that they're going to do in the game. Or, you know, it might even be more simple. It's athletes in the gym strengthening their bodies, ready to go and train, train to then compete in a stadium. It's like, it's very much a preliminary practice skill that I think is very, very helpful with mental Compulsions. But, you know, sometimes people say, well, when I'm doing it with you, it doesn't feel like life. Yeah, it doesn't, you know, and that's okay because this is an easier version. We're working with other people. It will feel just like life. And as soon as they think about ocd, the mental compulsions start very intensely. But there'll be other people who are sort of in a slightly more stable place, working on their recovery. And they'll say to me, like, you know, it feels so different to when I'm triggered. And I always say, well, think about those athletes. You go and see them in the gym, you'd say, well, that's not going to help you. When you're in a stadium with thousands of people and you're doing, you know, high pressured plays. And it's like, no, it's a preliminary thing that's built into it. I think that, you know, it's the kind of thing you could be practicing daily or weekly or as part of, you know, I always think, you know, we want to be building these ACT skills and again, could be using other toolkits to do it. It could be metacognitive therapy, it could be mindfulness stuff like, like John Hirschfeld's mindfulness based approaches, things like that. Whatever it is, it's some way of learning to observe your mind and observe feelings and to be with them, not take them as evidence of anything. Be able to stand back and observe them just as phenomena in the moment and then control our attention. So we want those ACT skills and we want to be doing erp. And for me, that's very much integrating ACT into it. But we obviously want to be doing exposure and response prevention and then we want to be responding well in the moment. So we're doing our skills really well in the moment as we're facing OCD each day. And we want to have those different pieces in place. And so this could be part of the ACT skills that you're doing. I have some guided practices where I start with dipping in and out the stream. Then we'll do values based ERP or erp, but we're emphasizing values and skills and then, then might end with self compassion. So you can sort of flow these things together in practice sequences. And if anyone wants to look at some of the ways I do that, have a look on Johnny say Therapy YouTube channel where I've got the OCD skills playlist and I've got different versions of dipping in and out the stream. And then also Russ has put A lot. Russ Harris has put a lot of this material out very openly, so through his website you can get. Get worksheets and guided audios and there's a lot of it on YouTube as well. And he obviously did the great episodes with you on. On dropping anchor and things.
- [52:41]
Stuart Ralph
Yeah, yeah, he did, yeah. I'll link to all that. Yeah. Hopefully this has given people a taster on how act, at least some of the ACT skills. Obviously, we didn't talk about ACT and the Hexaflex and the six core processes, but people can do their research on that. But hopefully this, because, yeah, sometimes that can get too theoretical. So it's nice to go straight to the skills.
- [53:06]
Jonny
Exactly.
- [53:07]
Stuart Ralph
ACT is very much doing therapy, I think, much like erp.
- [53:12]
Jonny
Yeah. And let me say one thing on that. Sorry to cut in, but one thing I see when. Because a lot of people integrate act alongside ERP, and we saw in the update of the IOCDF's guidance, they're talking about ACT as an adjunct ERP as recommended sort of treatment. So our colleagues and friends in America, obviously a lot of people integrate in this. A lot of people over in the UK are as well. When I worked in two NHS services, lots of brilliant CBT therapists were integrating ACT into erp. So lots of people are doing this. And the mistake I sometimes see people make is just talking about metaphors, just talking about maybe doing one mindfulness practice, one session. And the thing I'm passionate about it is repetition. It's like every session, there's some people. I would do months of dipping in and out the stream and every session we're starting with it and we might be doing ERP as well and other things as well, but the power in ACT is repetition and hopefully our clients are practicing it outside a session and they've got a daily practice or a daily ISH practice, but at the very least, we want to be doing it with them in session and not just talking about a metaphor here and doing one body scan and going up yet try and integrate that into your erp. It's no, let's directly practice and train it until it becomes second nature and we go from the sort of unconscious. There's that learning process of like, unconscious incompetence to conscious incompetence, to conscious competence to unconscious competence. We want to progress through that with ACT skills so that they become this automatic thing that, you know, for me, if I'm responding to intrusive thoughts, I'm not having to go right now. I have to do dropping anchor and how do you do it? It happens automatically because it's so, so well trained, you know, and that's just a matter of time and effort. So, you know, that's the big thing I see with people is like just sort of talking about it and not practicing it and Enough.
- [55:31]
Stuart Ralph
Yeah, yeah, it's. It's easy to get pulled into that trap of talking about it, you know, I definitely have to catch myself sometimes. But yeah, great way to end. I'm sure it's been helpful to. To some people. Yeah. Thanks Johnny, for your time, as always.
- [55:47]
Jonny
Yeah, great talking to you, Stu.
- [55:50]
Stuart Ralph
Thank you for listening to this week's.
- [55:51]
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- [56:02]
Stuart Ralph
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- [56:14]
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- [56:16]
Stuart Ralph
And quick disclaimer. Guys, this podcast is not therapy. It is not a replacement for therapy. Please seek treatment from a trained professional and until we speak, take care.