Dr. Moses Appel (Edited by Matthew Shields)
Whether you're a loved one of someone with OCD or you experience the disorder yourself, learning about OCD can sometimes feel like trying to hold back a tidal wave with a teacup. As we explored in my last blog post, there are many subtypes of OCD, some of which are more recognizable in the general milieu than others.
Additionally, we clarified that each person with OCD experiences their obsessions and performs their compulsions in unique ways. If you haven't checked out my blog post, Inside the Loop: Understanding and Overcoming OCD, I highly recommend that you do so before reading this article.
Remember that OCD is a disorder characterized by recurring obsessions and compulsions. Obsessive doubts trigger intense distress in individuals with OCD, prompting them to alleviate it through compulsive behaviors. These compulsions provide temporary relief, but the cycle of triggering experiences, distress, and compulsions ultimately intensifies, leading to more persistent and severe obsessive anxieties over time.
Recall that Exposure and Response Prevention (E/RP), sometimes called "ritual prevention," interrupts the OCD loop by encouraging individuals to refrain from engaging in their compulsions while intentionally exposing themselves to triggering situations. Doing that can break the cycle because when one engages in response prevention and refrains from compulsions, they learn to tolerate the distress that was caused by the obsessions. As they build distress tolerance, the pressure from obsessive anxieties gradually fades on its own, and the entire OCD theme loses its significance.
Though understanding the ideas behind ERP is easy, putting ERP into practice with vigilance and purpose can be challenging. This is true for clients and practitioners alike, so it's essential to be cognizant of several big-picture ideas of OCD to stay the course of treatment.
Here are 10 critical foundational concepts to keep in mind when treating OCD:
1. “OCD Brain” Gets You Further from the Truth, Even Though It Makes You Think the Reverse.
People with OCD allocate tremendous amounts of time and cognitive resources ruminating over their obsessions because they assume that there's meaning and truth to them. This only gets them further from the truth. Here's an example: one day, someone thinks I might have accidentally said something offensive during my conversation with my friend. They'll never speak to me again if I don't immediately apologize. While it's essential to be mindful of how we communicate with others, the chances that an entire friendship will dissolve because of a potentially offensive comment is extremely unlikely.
Instead of obsessively thinking about what was said, deliberating on the precise way to apologize, and apologizing because of fear rather than values, I would advise someone in this scenario to adopt what Jonathan Grayson calls the "Gun to the Head” approach. Imagine someone pointed a gun to your head and forced you to answer the question immediately: Will my single comment – one that may or may not have been offensive – destroy my friendship? Obviously, your answer would be a resounding No! By doing this, instead of ruminating, obsessing, and inappropriately apologizing without properly deliberating, one distances themselves from the message OCD tells them and consequently comes closer to the truth.
2. The Only Option in Life Is to Accept a Measure of Uncertainty Because the Alternative is Unrealistic and Leads to a Dysfunctional Existence.
If I had to describe OCD in one sentence, it would be "Obsessively trying to attain certainty where there can't be." After all, OCD is called the “doubting disease” for a reason. People with OCD often begin their journey down the proverbial rabbit hole with phrases like “what if,” “but maybe,” and “How do I know for sure?” Since everything in the world is technically and metaphysically possible, trying to answer these questions will lead one down an agonizing path of further uncertainty and, ultimately, misery.
Try this out for yourself. Ask yourself if you know that your father is your actual father.
Make sure to challenge any of your proofs because, after all, isn’t there still a remote chance that he’s not actually your father? Do you see how impossible and unfulfilling this type of thinking is? Even though you could always ask questions, you know he’s your father! What is gained by going through intellectual exercises like this?
It’s critical to recognize the lifelong consequences of needing certainty and then choose instead to live a more functional life grounded in one’s values. That way, one realizes that it does not make sense to engage in endless compulsive rumination and behaviors to achieve a false sense of certainty while robbing one's potential from before one's very eyes.
3. Analyze the Pros and Cons of Falling Victim to Compulsive Behavior.
Recognizing that one has OCD doesn't make the disorder go away. Progress only happens through a lot of hard work. When faced with a triggering scenario, one must ask, "What are the pros of engaging in compulsions, and what are the cons?” "What are the pros of engaging in treatment, and what are the cons?" Hopefully, asking these questions can help a person with OCD more completely commit to the work they're doing in therapy. In fact, considering the pros and cons at the beginning of treatment can bolster a person's resolve later when the work is painful.
It is also helpful for clients to ask themselves which of these two paths will lead them to a more successful and happy life. Let's pretend you're on your deathbed at the ripe old age of 101. What would you want your life to have looked like? A life of constantly chasing certainty and endlessly ruminating and engaging in compulsions? Or a life that you lived according to your values while tolerating the inherent uncertainties that are part of the human existence?
This technique is borrowed from Acceptance and Commitment Therapy (ACT) which helps people identify their values and commit to living life according to them.
Ultimately, one needs to refrain from rumination (obsessively overthinking and replaying things in one’s head ) and compulsions at all costs to treat their OCD. Whether through rewards, reminders, or motivational phrases, one must consciously decide not to ruminate to get better. The ultimate reward for choosing not to ruminate is unshackling oneself from the grips of OCD.
4. OCD Makes People think they are Guilty Until Proven Innocent
The messages OCD tells the brain can be highly persuasive. Let's say that someone has an intrusive thought to drive into a sidewalk full of pedestrians. Most of us recognize that this is an intrusive thought and means nothing. For someone with OCD, they might think that this means they might be a mass murderer and need to be locked up. This is because they take the approach of “guilty until proven innocent,” where they feel the need to conclusively prove to themselves that they are not a mass murderer. However, as mentioned above, it is impossible to prove thoughts like these with 100% certainty.
Instead, people must recognize that experiencing intrusive thoughts does not mean that they now must prove them wrong. The opposite is true: one’s innocent until proven guilty. This concept comes from I-CBT, Inference Based Cognitive Behavioral Therapy, and is extremely helpful to be mindful of when treating OCD
5. “Healthy Aggression”
It is critical to remind ourselves that “healthy aggression” is part of the human experience. All people have intrusive thoughts of an aggressive nature from time to time. Usually, we brush them off as thoughts that have no bearing on who we are as people. For people with OCD, however, the brain categorizes these intrusive thoughts as character-defining impulses that must be addressed. Using a concept from psychodynamic therapy, I aim to cultivate an awareness within my patients that “healthy aggression” is part of being human.
For instance, if a patient shares that they were so frustrated after their team lost that they felt like throwing the TV remote but chose not to, I guide them to focus on the fact that they had the feeling but didn't act on it, rather than fixating on their unsubstantial feelings of anger. Allowing one’s mind to be creative and experience extreme thoughts without overreacting to them would go a long way toward recovering from OCD.
6. Developing and Living with Functional Certainty
I find that people with OCD are often extremely analytical in the way they process the world around them. They understand that their obsessional anxieties aren't 100% improbable, and they argue that since there's a possibility their worst fear will come to fruition, they should remain vigilant. I tell them it's impossible to gain the absolute certainty they want with their anxieties. This isn't unique to people with OCD; life is inherently uncertain, and to succeed, we need to recognize that. Instead, I work with my patients to live life with 'functional certainty.' I-CBT (Inference Based Cognitive Behavior Therapy) a different approach from ERP (Exposure and Response Prevention), informs this concept. In my clinic, I often use both methods in conjunction.
Instead of trying to operate vis-à-vis their anxieties with machine-like precision, it's better to gain a measure of “functional” certainty and then move forward. Suppose that one day, a person encounters an intrusive thought, saying, What if I push someone off the subway platform? Instead of immediately moving away from the platform or avoiding taking the train altogether, I suggest they ask themselves, Do I really think I might push someone off the platform? No. Then I'm confident enough (aka “functionally” certain) that I won't do it this time. This doesn't scientifically guarantee that they're not a person who would do something like that, but that's not what we're looking for. Living life with “functional” certainty (as opposed to “absolute” certainty – which does not exist) is imperative so as not to fall into an endless quagmire of doubts. If one requires “absolute” certainty in life, they live in a prison of fiction of their own making, hoping for a reality that isn't possible.
7. OCD Transports People from Reality to Fantasy Land; the More One Engages in the Fantasy, the More Real it Feels
This is a foundational concept for OCD. Let's say that someone ruminates over whether they might have hit someone during their morning commute. They think that maybe they heard something but cannot be sure, so they decide to go down what I call “imagination lane.” They ask themselves, if they did hit someone, where did the accident happen? They admonish themselves for listening to music because it might have caused them to lose concentration. They wonder who the person they hit might have been. They worry about what’s going to happen to them now that they’ve been hit by a car, and they worry, too, about what will happen to themselves. Are they going to go to jail? How will they apologize to the victim’s family?
They’ve built this whole story for themselves, but in truth, probably nothing happened. This person has completely lost the plot; they’ve left behind reality for fantasy land. So, what should they have done differently? They should have never gone down “imagination lane” in the first place! Fantasy land is like eating a delicious cake: once started, it’s very difficult to stop. Therefore, the key is recognizing when one’s mind begins to veer from reality and immediately stopping it from going to fantasy land. Instead, they should ground themselves in the here and now and go about their day.
8. OCD Is Like the Matrix, so It’s Critical to Keep Resolutions Made from Outside the Matrix
For those unfamiliar, the film The Matrix explores a dystopian reality where humanity is unknowingly trapped in a simulated world created by machines to control their minds. Similarly, when triggered in an OCD moment, it can feel like one’s stuck in the matrix (an altered reality), lacking the ability to use logic to disentangle oneself from the OCD trigger. Therefore, devising a plan as to how to respond to OCD triggers prior to actually being triggered can help prevent people from getting trapped in OCD’s cobweb.
There are different types of responses that my patients like to use. For example, when the brain gives triggering messages, maybe respond; This is just a thought. Good one, brain, you almost got me there. For the crowd that reacts well to irreverent humor, think, You're totally right, brain! If I don't take precautions, I will probably stab my friend. In fact, I probably already have without realizing it!
Another type of response people like is one that's gentle and assuring. Instead of demonizing our brains when operating with faults, recognize that the brain is misguidedly trying to keep us safe. Think: Thank you, brain, for trying to keep me safe. I'm okay at this moment, and I'll take it from here.
Ultimately, the idea is to resolve ahead of time to not give in to the OCD triggers and have a prepared response to use in the moment of the trigger.
9. OCD Doubt Is Usually Triggered by a “What If” Or “Maybe,” Not by Concrete Information from the Here-And-Now
This item explores how to differentiate OCD doubt from actual doubt. One way to identify an OCD doubt is if the doubt contains the words "what if," “but maybe,” or “how do I know for sure?” If one’s thoughts look like Maybe I'll burn down my house, or What if I'm a child-killer? It's best to avoid taking those questions seriously and instead recognize the thoughts for what they are: silly OCD triggers. On the other hand, if one has tangible, real-life reasons to question like perhaps I should switch where my kid goes to socialize because there's not enough adult supervision, that's a doubt worth looking into.
10. OCD Cannot Survive Without Active Participation
Thoughts and feelings only have as much power and meaning as we give them. The real trick for people with OCD is to avoid participating in the OCD loop as much as possible. If one's able to refrain from engaging in obsessions and compulsions, the anxiety will eventually die. Plants require CO2; people need food and water; obsessional anxieties require active involvement.
Above are ten foundational concepts I like to utilize when treating patients with OCD to help them stick with their Exposure and Response Prevention (E/RP) therapy. My hope is that if you're a mental health practitioner, a loved one of someone with OCD, or have OCD yourself, you can pick and choose from this list to transmit agency to the process of treating OCD. I'm confident that these ten principles can keep one from engaging in compulsions and, ultimately, live a freer and more fulfilling life.
Disclaimer: All characters and scenarios in this post are entirely fictional. This content is intended for informational purposes only and is not a substitute for professional therapy or treatment from a licensed mental health provider. To contact Dr. Appel, please email office@ADOPsychologyCenter.com.