The Truth About OCD
WHAT PEOPLE THINK OCD IS
Howard Hughes in the “The Aviator.” Melvin Udall from “As Good As It Gets.” Roy Waller in "Matchstick Men." What do all of these cinematic characters have in common? They each portray a character afflicted with Obsessive-Compulsive Disorder or OCD.
While these portrayals make for interesting and dramatic movie material, they do not necessarily give the most accurate representation of OCD. Many think they possess a good understanding of what Obsessive-Compulsive Disorder is because of how it is presented on television and in movies.
Someone with OCD:
WHAT OCD REALLY IS
When people are suffering from OCD, there is a lot more going on beneath the surface. In most cases, people have thoughts, worries, and/or mental images that cause them significant emotional distress. They are persistent (the obsessions), and the person cannot seem to shake them. In order to get rid of the extreme anguish he or she is experiencing, the person finds that certain behaviors, if they are performed in a way that feels right, will cause that person to feel relief.
Because it worked, the person will start believing that the way to minimize these intense feelings is to repeat the actions in that exact manner (the compulsive behaviors). They will start to think that anything less won’t bring the emotions down to a more manageable level or ideally, eliminate them.
People with OCD know that the connection between the obsessions and compulsions makes no sense, other than it works to help them feel relief. They aren’t delusional. Logically, they get it. Emotionally, they know it is a means to an end, which is to decrease the extreme and unwanted feelings. They don’t want any of it, but they don’t feel as if they can stop it any other way.
Note: There is a lot of discussion in the mental health and medical fields as to whether “Pure O,” or an obsessions-only version of OCD exists. In the vast majority of cases there is some attempt to decrease emotional distress through some type of compensation behavior. This is why there is no official Pure O subtype. However, there are many individuals who report only experiencing the obsessions.
Unfortunately, even when the sequence of obsessions and compulsions is completed, the relief achieved does not last long. People with OCD are keenly aware of this, but again, they often see no other viable options for feeling better. Quickly, the tension and torment begins to build once more, creating the urge to engage in the compulsive behaviors again to experience some peace, even if it is short-lived. There is no such thing as lasting calm, instead they live with the feeling that the cycle never stops.
It can, and usually does, get worse over time. The routine of touching, checking, washing, counting, arranging, collecting, repeating, cleaning, praying often increases in complexity and the time needed to complete it. Achieving that temporary reprieve gets harder and harder. The old steps don’t have the same results they used to, and so more needs to be done. This can lead to more compulsive behaviors, further interfering with their life.
MY APPROACH (WELL, ONE OF THEM) TO TREATING OCD
There is a type of Cognitive-Behavioral Therapy has been shown to be most effective in treating OCD. It is called Exposure and Response Prevention (often abbreviated as ERP or EXRP).
ERP is an active treatment approach in which we work together to dismantle that obsession-distress-behavior-temporary relief cycle. We create situations that are designed to elicit the obsessive thoughts you or your child experience in your daily life. Then, in a supportive setting, you experience the obsessive thoughts but do not engage in the usual compulsive behaviors. By experiencing the emotional reaction, you have the chance to see that the dreaded consequence (loved one being in an accident, getting sick and/or dying, acting in a manner that is dangerous and out of control) doesn’t happen (which logically, you already knew).
It’s important to keep in mind that when someone is intentionally confronting situations and thoughts that elicit distress, emotional reactions are bound to occur. We are human and there is no shut-off switch for our feelings. For the treatment to be effective, we need to take the distressing emotion and learn to handle it in a healthier way.
Because of this, we find a pace and a style that is comfortable for you. But please keep in mind, if you didn’t feel any distress at all, we wouldn’t be able to make any therapeutic changes. We will also strive to keep the treatment from becoming so anxiety-provoking that we run the risk of overwhelming you. This could cause you to fall back into the old habits that we are looking to disrupt.
We can think of this in terms of Goldilocks...not too little distress, not too much distress, just the right amount makes for an effective treatment. Throughout the course of your treatment, we continue to talk about where this range is for you. With enough success and momentum, we eventually work our way up to the more difficult situations (which might not be too harrowing when you get up to them).
The practice of creating these situations is collaborative. Nothing happens without us first discussing what would be beneficial to you and what you should expect. If you say something might be too much and you’re not ready for it yet, then we don’t do it that day.
All feedback is listened to and incorporated into the therapy. I don’t like surprises, and you should not anticipate any. The reality is that the process works best when you develop your own challenges both in and out of our sessions. I’ll guide you in creating them, but the more you take the lead, the more progress you will make. Confronting your fears both in- and between-sessions is extremely important and helps elicit lasting gains from this therapy style.
Through the ERP process, people are able to disconnect their obsessions from the compulsions, decrease the intensity and frequency of the obsessions, become free to learn healthier ways of reacting to their worries and distress, and reclaim a lot of time, energy, and opportunities in their lives.
MY APPROACH TO TREATING OCD, PART TWO
There’s another set of techniques that can be effective in treating OCD. They involve less confronting your obsessions and situations that trigger the compulsions, which can be more appealing to some people. It does still center around changing your responses to obsessions and actions in situations where the OCD occurs.
Using this treatment style, we would develop alternative strategies for dealing with the obsessive thoughts. Rather than squelching them altogether we can use mindfulness- and acceptance-based techniques. We will work on identifying when your brain is giving you troublesome experiences, like thoughts, worries, mental images, and/or physical distress, then responding to them with acknowledgment and letting them go.
This technique is based on the awareness that all thoughts come and go on their own. You can’t control what messages your brain gives you, especially if it is worried about something bad happening. We can work on helping you understand that the worry exists, but allowing it to run its course and then fade away.
This being said, acceptance is not a technique where you have to learn to love your unwanted thoughts and emotions. But you can develop a different type of relationship with those internal experiences, one that allows you the freedom to improve your life. This technique helps you accept that you are having the thought or experience and that it is natural and okay. Nothing bad is happening and you are safe.
You’re not going to become best friends with your obsessive thoughts. The thing is that people who have “gone to war” with their intrusive thoughts and emotions will tell you that they are certainly not winning. They have sacrificed a lot in their lives in the name of these neverending battles. How might your life be different if you called a cease-fire?
The acceptance method can help you allow the natural life cycle of a thought to run its course, without feeling as if you have to eliminate it from your mind. This is the core tenet of this treatment approach.
Another method we can employ can be used directly in situations where the compulsive behaviors occur. We work towards developing a set of more flexible behaviors, rather than using the more dysfunctional ones that only serve to intensify the emotional distress over time.
Changing habits won’t be a walk in the park, but if you are willing to take on the thoughts, physical sensations, or urges in a different way, then you can achieve a level of freedom you might have once thought was impossible. In many cases the obsessions, urges to act in certain rigid ways, and distress that comes with OCD may still crop up, but these parts of your experience will no longer run your life.
WHAT OCD TREATMENT IS RIGHT FOR YOU?
Medications are also effective in treating OCD, but if you are open to it, ERP is ideal as a first-line treatment. Acceptance-based approaches are gaining momentum and have positive results in the research, but using the tried-and-true method first is a good option. It has a very long track record of success and no side effects. Also, people really like the experience of actively conquering their fears.
If someone is really hesitant towards this style of therapy, it is okay to begin with the Acceptance strategies and eventually add in some ERP at a later time. Most of the time, my approach will include components of both ERP and Acceptance-based strategies.
COMMON QUESTIONS ABOUT OCD
It’s been said that OCD goes after what you care about the most. If you didn’t really care about the potential consequences that the worry contained, you would be able to easily brush it off and it probably would have never taken hold.
My goal is to help someone get back to what would be a normal and/or expected level of the behavior. Washing hands once, instead of never or 10 times. Checking once to see if the oven is off, as opposed to checking it 5 times in a row. If it is realistically important for something to be lined up or symmetrical, that’s fine. But if there are no real-world consequences for it not being that way, then allowing that to occur and reaching a place of peace with it.
Yes. As is always the case, the framing of it has to be adjusted to the child’s level of maturity, understanding and abstract thinking skills. Most children understand that a part of their brain is giving them weird messages and making them worry, but there are things they do that help them feel calm again.
For either style of treatment described, this is a necessary component. Placing yourself in the situation where the OCD occurs is what allows the emotional part of your brain to relearn how to deal with fear without having to resort to rigid and compulsive behaviors. The more of these experiences you give it, the more free you become.
THE FINAL WORD ON OCD
OCD can be debilitating if left untreated. The constant cycle of thoughts, emotions and behaviors can leave you feeling trapped. What’s exciting is that there are several treatment options that can significantly improve almost every aspect of your life.
If you or someone in your life is struggling, there are things you can do to greatly improve your life. It may seem like the solution is out of reach, but for every problem, there is a solution.