Obsessive Compulsive Disorder (OCD) is a condition that involves intrusive thoughts, images, or bodily sensations that cause an uncomfortable emotion (e.g., anxiety, guilt, shame, etc..), which leads one to engage in compulsive behavior (e.g., mental, behavioral) to alleviate that uncomfortable emotion. OCD can be thought of as a “broken alarm system,” meaning the part of your brain responsible for detecting threats (i.e., amygdala) is overactive compared to individuals without OCD. This is better known as our “fight-flight-or-freeze” response to fear. An overactive amygdala leads one to experience anxiety over perceived threats that may not actually cause harm. Due to this hyperactivity, individuals with OCD will state that their obsessions “feel real,” leading them to believe their intrusive thoughts are relevant or reflect their character. OCD encompasses a wide range of themes (please refer to the OCD education tab). OCD themes develop based on the principles of classical and operant conditioning. If you have some familiarity with psychology material, the names Pavlov & Skinner may be ringing some bells.
Classical Conditioning (Pavlov): a stimulus is paired with an involuntary response
Operant Conditioning (Skinner): voluntary behaviors are reinforced through consequences
OCD first develops through classical conditioning, when the involuntary fear response (i.e., broken alarm system) becomes paired with intrusive thoughts or images. While everyone has random intrusive thoughts (e.g., “What if I want to take this knife and stab my partner?”), individuals without OCD will typically acknowledge these thoughts as odd and move on with their day. However, if someone with OCD had that thought, it may be paired with that involuntary fear response. This results in high levels of emotional arousal, leading to the thought “feeling real.” One may start to believe they want to kill their partner, leading to increasingly more emotional arousal.
As humans, we want to do everything possible to stay in emotional homeostasis (i.e., feeling content/grounded); therefore, individuals with OCD will start to engage in compulsions to try and alleviate their emotional arousal. In the harm OCD example above, some compulsions may be mental (e.g., self-reassurance, ruminating to figure out if the thought is “real”) or behavioral (e.g., hiding knives, avoiding partner). This is when operant conditioning kicks in – once we feel some anxiety reduction from a compulsion, we want to do it again! The cycle of obsessions and compulsions involves negative reinforcement, meaning if I do a compulsion, I get rid of discomfort, so I will likely do it again. The thing about compulsions is that the relief only lasts a short time. Many individuals with OCD will feel like thoughts are “stuck” in their heads or see “signs” that these intrusive thoughts are true. This is because as we continue to engage in compulsions, we reinforce the idea that this intrusive thought is a threat, which makes the brain hyperaware of the thought and anything that might relate to it.
Over the years, growing research and clinical interest have shed light on OCD, revealing that it encompasses far more than just hand-washing or flicking light switches. Nevertheless, the initial OCD episode can leave one feeling “crazy” or “out of control” due to the ego-dystonic (i.e., separate from one’s belief and value system) nature of many intrusive thoughts and OCD themes. Some of my clients have even described their first onset as traumatic. Although OCD has become better understood, the diagnosis can feel isolating and stigmatizing. However, it is essential to remember that you are not alone, and if you are reading this post, you are on the right track to getting appropriate care. Through my doctorate training and career, I have worked with countless clients with various OCD themes and presentations, which has enabled me to learn effective ways to treat this disorder. There may not be a “cure” for OCD, but you can learn to live WITH OCD and get back to what is most important to you – your values.
Embracing Uncertainty – Living with the Maybe
The nature of OCD often leads people to question everything, including their own OCD diagnosis. Even after being diagnosed, the initial relief may only be temporary as the dysfunctional alarm system of OCD reactivates. If this resonates with you, I imagine you understand that all the answer-seeking, Googling, arguing with the thoughts, or receiving reassurance is never enough to get complete relief. OCD is what I like to call the “answer gremlin.” It will want more and more answers to try and prove or disprove your intrusive thoughts/images. However, the answer gremlin is never fully satisfied. Even if I were to give you an OCD diagnosis right now and tell you all your intrusive thoughts are irrational, it wouldn’t matter!
This makes OCD frustrating, given that many intelligent, logical, and rational individuals understand that OCD is illogical. However, no matter how hard you try, you cannot out logic OCD. So you might think, “Uh, okay, so what do I do then?” Well, we stop giving the answer gremlin what it wants – answers! When you boil it down, the core fear of OCD is uncertainty. To try and gain certainty, we seek answers or problem-solve (i.e., compulsions). However, we live in a world of uncertainty; therefore, this is an impossible task. To learn to tolerate and live with OCD, we must embrace the uncertainty of the unknown.
We accomplish this by using non-engagement phrases (e.g., “Maybe,” “I’m not sure,” “I guess we’ll see”) when OCD asks us questions. So when one has the intrusive thought, “What if I want to stab my partner with this knife?” the skillful response would be, “Maybe.. and I am going to continue to cut up this onion and go about making dinner.” This is also called “response prevention” in Exposure and Response Prevention (ERP) therapy, which I will discuss later in this post. If you have never been in OCD treatment, this response may seem unconventional or scary. However, when we use non-engagement phrases and embrace uncertainty, we show OCD that these thoughts are not a threat. We are demonstrating to the answer gremlin that these thoughts are insignificant and do not need to be answered. The more we practice sitting with the discomfort of uncertainty, the fear response in our brain begins to quiet down, ultimately leading to symptom reduction.
Willingness: The Key to OCD Treatment
When I start with a new client, they are typically experiencing high levels of distress due to their symptoms. Given what we learned about the brain sending false alarms, this makes sense! A new client will typically be very anxious; if it is their first episode of OCD, they may also feel confused and frustrated. However, one of the telltale signs that it is someone’s first encounter with OCD treatment is the strong urge to get “rid” of all of their symptoms. They want to start OCD treatment to be “fixed” or “cured” of their disorder. It is important to note that there is no definitive “cure” for OCD. However, ERP is highly effective and leads to significant symptom reduction. The very fact that I have built my career as an OCD specialist and am writing this article attests to its success! However, it is crucial for you to understand that we do not engage in ERP treatment to get “rid” of uncomfortable emotions, thoughts, images, or body sensations. We engage in ERP treatment to show our brains that we are WILLING to tolerate these uncomfortable internal experiences. If there is any phrase you remember from this article, let it be this:
The more we resist OCD, the more it will persist!
I understand you may be thinking, “Melissa, why would I start ERP treatment if we aren’t going to get rid of my OCD?!” I also acknowledge that this may seem very counterintuitive. Still, to show our broken alarm system that these internal experiences are not a threat, we must be willing to experience them. The term willingness is a significant aspect of Acceptance and Commitment Therapy (ACT) and means “making room” for all the uncomfortable feelings, thoughts, physical sensations, memories, etc. Willingness is about living with the AND instead of the BUT. (e.g., “I want to go out with my friends AND I’m anxious about it” instead of “I want to go out with my friends BUT I’m anxious.”). Willingness leads us to pivot toward our discomfort rather than avoiding or trying to reduce it. This shows the brain that your uncomfortable internal experiences (e.g., anxiety, intrusive thoughts) are no longer a threat, reducing the severity of your symptoms. When we begin to pivot toward willingness, we also build distress tolerance (i.e., our ability to handle discomfort or challenges). A helpful metaphor is imagining OCD as a giant hairy monster (i.e., Sulley from Monsters Inc.); the more we run away from Sulley, our fear and anxiety will continue to be reinforced. However, if we welcome Sulley, we might initially feel scared but will eventually adjust to him being there and feel less anxious. Now we can sit across from Sulley and realize he is not as scary as anticipated! Now we are pivoting our energy from trying to keep Sulley out to focus on what matters to us. Remember, willingness isn’t to get rid of your symptoms but to fully experience them. The goal is to welcome uncomfortable internal experiences AND still pursue your value-based life.
Meditation and mindfulness have gained significant attention in today’s current societal climate. However, it is essential to note that there are several misconceptions surrounding these practices. I like to think of mindfulness as an umbrella term, and meditation is one way we build and practice this skill. Mindfulness is being aware of our current thoughts, emotions, bodily experiences, and environment in the present moment. It is about observing these experiences from a non-judgmental and non-reactive lens. This is one of the most valuable skills in OCD treatment because it helps us observe intrusive thoughts/images and anxiety from this lens.
For example, when I start working with clients, they say, “These thoughts are awful!” or “My anxiety is so bad and terrible!” When we constantly judge our inner experiences as BAD or AWFUL, this signals to the brain that they are threatening and need to be avoided or eliminated (aka bring on the compulsions!). One of the first things I do in treatment is point out an individual’s judgmental language when describing these inner experiences. We can effectively disengage from obsessions by using neutral language and focusing on describing rather than reacting.
Reactive: “These thoughts are so annoying and terrible. Anxiety is so awful.”
Mindfully: “I’m noticing many intrusive thoughts and anxiety right now. It is uncomfortable, and I don’t like the thoughts, but I can non-judgmentally observe and let them pass.”
This may seem silly, but changing our language around thoughts and emotions plays a crucial role in the treatment process. It allows us to create a different relationship with our internal experiences. It can be uncomfortable to experience a wave of thoughts and anxiety, but responding to them with negativity and judgment only intensifies your anxiety. Now you are anxious about being anxious! Instead, if we can be willing can ride the emotion wave, notice the discomfort, and recognize these are thoughts and emotions, the wave will come and go much quicker. This is much easier said than done and takes practice through meditation.
When I first talk about meditation with my clients, most will say they have tried it but don’t see how it’s helpful or get frustrated because they can’t “clear their head.” This is one of the biggest misconceptions that I hear. Meditation does NOT mean sitting down and thinking about nothing. We cannot control our thoughts during meditation, but we can control how we respond to them! A guided meditation will typically pick something as an anchor to focus on, such as your breathing. The goal is to focus on your breath and non-judgmentally acknowledge whenever a thought or emotion pulls you away and then shift your attention back to your breath. This lets us notice and observe that thoughts or feelings are present while choosing not to react. Even if you have to shift back to your breath every few seconds, that is OK – it’s how you build your mindfulness muscle!
Naming Your OCD Voice
Throughout this post thus far, you may have noticed that I talk about OCD as a different entity separate from you (i.e., OCD is never satisfied vs. YOU are never satisfied). Throughout my training with OCD specialist Dr. Steven Phillipson and learning from ACT, I have seen the transformative power of creating a separation between oneself and OCD. Many individuals with OCD feel confused and frustrated when their intrusive thoughts do not align with their beliefs and values (i.e., ego-dystonic). We are taught that our cognitions makeup who we are or reflect our character. From the example above, if an individual has intrusive thoughts about harming their partner, this may lead to them thinking – “I am a horrible partner,” “What if this means I don’t love my partner,” or “Am I secretly a murder?!” This then results in anxiety, confusion, guilt, or shame because this individual is using their intrusive thoughts to reflect their character. Two important things to remember in OCD treatment are:
- We CANNOT control intrusive thoughts
- We are NOT our intrusive thoughts
This may sound like a strange concept to you, but if you think about how many thoughts you have throughout the day, not all of them reflect your values and character. We all have intrusive thoughts that are creative and interesting. Suppose I am driving and have intrusive thoughts or images about swerving off the side of the road or running someone over. Does this make me suicidal or a murderer? No, it makes me a human with intrusive thoughts, which I can actively choose to separate myself from. To help my clients work towards this separation, I teach ACT defusion skills and have each client select a name for their OCD voice. Some clients like to keep it simple and call it their “OCD Voice.” In comparison, others prefer to use names different than theirs, such as Hillary, Jose, Craig, etc. When we name our OCD voice, it allows us to “defuse” or separate from intrusive thoughts, which enables us to recognize them for what they are – just thoughts! Intrusive thoughts only have power if we give it to them. Otherwise, intrusive thoughts are just bits and pieces of language and sounds without meaning.
Separating from OCD is hard work! However, through a combination of mindfulness and defusion skills, it is possible to develop autonomy from OCD. Remember, there is an inner YOU observing your intrusive thoughts, and this is the YOU that decides which thoughts to give attention to vs. label as irrelevant. You might wonder, “How do I know my voice vs. OCD voice?” This is a popular question amongst my clients. The answer is – that we will never know for sure! I imagine that answer may be anxiety provoking. Using this technique in itself is an exposure because we are taking the risk of labeling something as OCD. When you label something OCD, your brain will say, “But what if it isn’t?!” Our response is, “Okay, OCD voice, maybe it isn’t, but I am taking the risk and deciding to label it as OCD and continue with my day.” This phrase alone puts you in charge of your life instead of OCD dictating it! Building upon mindfulness and defusion skills also helps you to engage in the most effective treatment for OCD – Exposure and Response Prevention (ERP).
What is Exposure & Response Prevention?
One of the most important ways to demonstrate willingness to your OCD brain is through Exposure & Response Prevention (ERP). If you have been researching treatments for OCD, you may be familiar with this term. Let’s break it down:
Exposure: Planned assignments (e.g., behavioral, imaginal) that target core OCD fears
Response Prevention: Resisting compulsions through disengagement skills
ERP aims to retrain your overactive fight or flight system and show your brain obsessions are not a threat. To do this, we must first be willing to engage in ERP. It is typical to experience resistance to engaging in ERP, given that you are told to face your fears. This is why a fear hierarchy is developed, which ranks potential exposures from least to most distress-inducing. An important thing to know is that your anticipatory anxiety about exposures is typically higher than actually engaging in them. Clients often report that their distress levels are lower than expected and wonder if exposures are “working.” When exposure therapy was first created, the thought was that if you “recreate” the emotion, you will habituate to it, resulting in symptom reduction. However, it is challenging to create the same level of anxiety in planned exposures compared to when you are naturally triggered in your environment. The analogy of being tickled rings true for ERP – it is much harder to tickle yourself than when someone else does because we know it is coming. This is similar to a planned exposure; since we know it is coming, we may not feel as anxious, which is ok! The underpinning effectiveness of exposures is the willingness to experience whatever comes up during them. We are saying – look, OCD brain, I am so willing to have these thoughts, emotions, bodily sensations, etc. I am going to expose myself to them purposefully. Over time our willingness to bring on this discomfort signals to the brain that these internal experiences are no longer a threat, and thus habituation occurs.
If you are thinking about or just starting ERP with an OCD specialist, you want to remember a few essential tips. First and foremost, we are not engaging in ERP to get “rid” of OCD symptoms. Many clients engage in ERP, desperately trying to relieve their symptoms, and if this is your mindset going into ERP, it will NOT be effective. If we are genuinely willing to experience these symptoms, then exposures are targeted to demonstrate willingness and acceptance instead of relief-seeking. Again, I understand this seems counterintuitive, but as stated prior, the more we seek relief within treatment, the less we will get it.
Second, ERP is hard work; you will only see change if you do the work outside of your therapy sessions. Your therapy session is typically only forty-five minutes 1x per week unless you are engaging in more intensive treatment. Forty-five minutes is not enough time to work on ERP, so most of the work you will engage in will be on your own. This is where discipline comes into play. I like to define discipline as consistent work towards a goal in the absence of motivation. I often hear things like, “I didn’t feel motivated to do exposures this week or “I didn’t find the time.” Motivation is an ever-changing feeling; its presence can be incredibly energizing. However, it is not a constant state and may fluctuate over time. Some weeks we will be tired, overworked, or overwhelmed with life responsibilities. This is when we practice discipline and make time in our busy schedules to do ERP because it is a goal based on our value of mental health. The moral of this paragraph is to do your ERP homework!
Lastly, effective ERP treatment is continuously practicing response prevention outside of exposures. I tell all my clients that they can do all the exposures in their hierarchy, but if they are still engaging in compulsions when triggered organically, they will not see results. Typically, I have my clients engage in response prevention and practice disengagement strategies before starting exposures. This allows clients to practice tolerating the distress of resisting compulsions before jumping into exposures. Remember, you still reinforce your symptoms if your behavior is inconsistent. This in no way means we have to be perfectly skillful. Treatment progress is not linear and does not equal perfection. Given this treatment’s difficulty, being kind to yourself along the way is essential! Overall, the secrets to skillfully engaging ERP are consistency, discipline, and, most of all, self-compassion.
Reclaiming Your Life Through Values
When you suffer from symptoms of OCD, you often lose touch with what is important to you, your values. One of the core fundamental principles of ACT is connecting to our values despite challenging emotions or thoughts. Values are belief systems that shape our goals, guide our behavior, and connect us to a meaningful life. Values are a compass that guides our behavior. There is a popular metaphor in ACT called “Passengers on the Bus,” which allows you to visualize yourself driving a bus, and the passengers on this bus are all your unwanted thoughts and emotions telling you when to turn and stop. You begin to realize that you are no longer in control of where you are driving the bus and that these internal experiences are in control. If you’re reading this right now, I want you to ask yourself are you driving the bus of your life, or is OCD? If you are constantly preoccupied with symptoms, seeking relief, and making behavioral decisions based on your fears, there is a good chance OCD is in the driver’s seat of your life.
So, you might wonder, how do I regain control of the bus? My first assignment with all my clients is a values clarification exercise to help them take a good look at what is important to them in life. Clarifying what is meaningful helps us guide our energy to what matters. If OCD drives the bus, your energy is probably dedicated to seeking answers/relief, engaging in compulsions, and avoiding. This leaves very little energy to connect to your values and leaves you feeling dissatisfied or even depressed. It is also important to note that OCD tends to attack parts of our values system (e.g., family, partner, health), making it seem more challenging to connect. This is when the power of AND comes into play again, and implanting this word into our daily language is crucial for getting our life back. You can have symptoms of OCD AND make decisions based on your values. Here are some examples below:
“I want to feel connected and close to my partner, but I have intrusive thoughts about harming them.”
“I experience intrusive thoughts about harming my partner AND have a fulfilled and loving relationship.”
Understanding that we can connect to our values AND experience symptoms of OCD allows you to regain control. This article is entitled Living WITH OCD because that is precisely what the goal is in treatment. We learn that we do not have to fight with or avoid our OCD but instead learn to walk alongside it through acceptance.
Acceptance: The Path to Recovery
Acceptance is one of the most powerful stances we can take in OCD treatment and within life in general. However, we don’t just wake up one day and say, “Okay, I accepted all the pain in my life. I am healed!” I like to think of acceptance as something we consistently strive toward and a daily choice. I believe many people confuse acceptance with liking something. We do NOT have to like specific thoughts, emotions, etc.. to accept them. A helpful metaphor is to imagine a bee buzzing around your head. You might start trying to push the bee away or run from it, but it keeps following you, maybe with even more vengeance. Then you realize that if you just let the bee buzz around, it eventually leaves. You don’t have to like a bee buzzing around your head, but you can accept its presence. This is precisely how we must look at intrusive thoughts, emotions, or bodily sensations. You don’t have to like the content of your intrusive thoughts or uncomfortable feelings, but you can accept that they are there.
You might be thinking (sarcastically), “Oh yeah, I’ll just accept these terrifying thoughts and anxiety, no big deal, Melissa!” I very much understand that this is easier said than done. Accepting OCD or any pain is hard work and takes consistent practice. We demonstrate acceptance by engaging in ERP and through our behavior. We show our OCD voice that we can have these symptoms AND live the life we want, which is what the path to recovery looks like. The more we practice acceptance of symptoms and focus our energy on our values, the quieter our OCD voice becomes. Acceptance looks like taking a stance and saying, “Okay, OCD, you can give me any obsession you want, I’m willing to experience it, and I will still make value-based decisions – Bring it on!” Remember, any therapist trying to sell you that they can “cure” your OCD probably doesn’t understand the disorder well. They are also already starting you with the unskillful mindset of unwillingness & relief-seeking. I do not give my clients a cure for OCD; I teach them a different way to relate to their symptoms, leading to symptom reduction and regaining their life. I teach them how to live WITH OCD.