All of us are unique and have individual differences in personality functioning. Most patterns of personality can have positive and negative aspects. When people have obsessional personality characteristics they may commonly aim to draw on a sense of order, rules or standards to exercise a greater sense of control in various areas of their lives. They may tend to be perfectionistic. The positive side of this is that people tend to be conscientious and reliable in many ways and to adopt high standards in various roles in their lives.
However, the disadvantage of such tendencies is that they can lead to rigidity, inflexibility, inefficiency and heightened anxiety, especially in circumstances of heightened stress. When such patterns occur it can help to learn to be more flexible. Paradoxically, “letting go” of control in various situations can lead to more effectiveness, efficiency and greater relative control in the long run.
Efforts to gain control in a situation become excessive and counterproductive when a person develops an Obsessive Compulsive Disorder (OCD). OCD is categorized as an anxiety disorder because it leads to feeling heightened anxiety in particular situations. Commonly individuals with OCD will make considerable effort to avoid such situations. Such a condition interferes with a person’s wellbeing, efficiency in dealing with various situations, and subjective sense of freedom and control in everyday life. This handout is focused in particular on promoting greater understanding of OCD reactions and psychological treatment strategies for addressing them.
What is Obsessive-Compulsive Disorder (OCD)?
Examples of obsessive-compulsive symptoms include excessively and repeatedly checking whether doors are locked, repeated excessive handwashing owing to fears of contamination, using rituals to “decontaminate” areas of one’s house, fears of having run someone over and driving back to check, persistently and repeatedly moving objects according to rigid rules of order or symmetry, or feeling unable to throw out worthless or worn out items. Such reactions typically involve both obsessions and compulsions. Obsessions are repeated and persistent distress-inducing thoughts, impulses or images (such as a thought that one may have left one’s gas oven on despite having checked it several times) which are intrusive, unacceptable, subjectively resisted, and seen as uncontrollable. The person recognizes the thoughts as their own, but as entering their mind against their will. Compulsions are repetitive behaviours (such as persistent excessive washing rituals or checking of locks) or mental acts (such as counting or repeating words in one’s mind), which the person feels driven to perform in a rigid or ritualistic way in an attempt to reduce distress associated with an obsession or to prevent a dreaded event (e.g. returning home to check yet again whether the gas oven was turned off to avert the risk of fire). The person typically recognizes that their compulsive behaviour is excessive and unreasonable. This helps explain why others will find that encouraging the person to desist from a compulsive act using logic or reason will tend to make little difference.
There are four main types of OCD:
- Checking/harm obsessions (e.g. checking locks, fear of hurting someone)
- Washing/Contamination (e.g. handwashing, decontamination rituals)
- Pure obsessions (e.g. counting, repeating words in a ritualized manner)
- Hoarding (extreme cluttering related to refusal to throw out worthless items)
Photograph: Boram Kim
By definition, Obsessive-Compulsive Disorder involves either obsessions or compulsions which interfere with one’s life by causing marked distress, costing considerable time (at least an hour per day), or significantly interfering with one’s normal routine or areas of life such as study, work, socializing or relationships. Approximately 2% of the population suffers from OCD. Many more people can have milder forms of obsessive-compulsive symptoms which fall short of an OCD diagnosis. They may nonetheless benefit from applying some of the OCD treatment principles and strategies listed below.
Attitudes and beliefs that promote OCD
There are a number of attitudes commonly associated with obsessive-compulsive patterns of behaviour which can promote rigidity and unnecessary stress in the interests of gaining greater control, but at the expense of flexibility, openness and efficiency.
Attitudes and beliefs associated with obsessional tendencies include:
- Inflated responsibility: Having an exaggerated view about one’s influence over the outcome of various events relative to multiple other influences.
- Overimportance of thoughts: tending to believe that thoughts themselves may make us act a certain way or cause particular negative outcomes to be likely. If we recognize a negative thought and then simply “do nothing” in response to it, the thought is less likely to have a negative impact on us: it will eventually pass, all the quicker when we are distracted from it.
- Overestimation of threat: Especially when anxious there can be a tendency to magnify the risk of specific dangers in terms of overestimating both their probability and severity. Worry is based on our view of the probability of a negative event and its likely severity. If we exaggerate either of these we will directly increase our level of unnecessary worry.
- Importance of controlling thoughts: People may fear being overwhelmed by anxiety, losing their mind, or facing some other calamity if they don’t control their thoughts. Paradoxically, aiming for more control over negative thoughts can keep us focused on stress-related reactions, whereas “letting go” control over thoughts commonly eases our arousal levels in the long run, especially with practice.
- Intolerance of uncertainty: Much of life is ambiguous, influenced by luck and variables beyond our ready control. Our memories for events are imperfect, and especially for routine events such as driving through previous traffic lights or locking one’s front door that morning. To challenge OCD rituals and to face fears means being prepared to risk uncertain outcomes. Preparedness to tolerate uncertainty commonly allows a greater sense of freedom, a more outward focus, and more responsive attention to our current circumstances.
- Perfectionism: Perfectionism is probably the attitude above all others that tends to induce the most unnecessary stress, depression, etc. At times it may help to apply ourselves to various situations in a conscientious and earnest way. However, there is a point at which the demands we place upon ourselves can become rigid or excessive and interfere with our wellbeing, efficiency and performance. Many situations do not require our absolute best efforts, especially when there are time constraints or other priorities. It helps to recognize that failure can be a helpful learning experience rather than a negative outcome which reflects on one’s worth. Even the most favourable course of recovery in OCD is likely to be gradual, punctuated by lapses, and involving some remnants of OCD behaviours in the long run. But even imperfect recovery can be more than “good enough” to allow one to fully and happily participate in all of one’s life roles. With OCD aiming for an imperfect recovery is better than the alternatives.
Treatment of OCD
There is some good news and bad news about treatments for OCD. First the bad news& Psychological therapy interventions for OCD typically include a great deal of discomfort, especially in the short term. Furthermore, even successful treatment of OCD may not completely eliminate the intrusive thoughts and/or the anxiety that comes with them. The good news is that you don’t have to entirely get rid of intrusive thoughts for a good recovery. OCD is not so much something to be “fixed”. Often people make very acceptable progress by learning strategies to manage obsessive-compulsive reactions and minimize their impact so they no longer significantly interfere with their everyday life. When such relative recovery is achieved, anxiety levels commonly diminish and intrusive thoughts typically reduce greatly in frequency, but some residual intrusive thoughts and/or anxiety may remain. People gain further emotional resilience as their confidence increases in managing such reactions which then no longer represent a threat.
There are well-established psychological treatment interventions for OCD. Paradoxically, a key strategy in dealing with obsessions is to acknowledge the obsessional impulse and then “do nothing”. There is often little to be gained by actively attempting to suppress or block out intrusive thoughts. Such attempts commonly make the situation worse. Trying to block out obsessional thoughts has been described as similar to attempting to eliminate gas bubbles in soft drink using one’s finger the soft drink bubbles are like obsessional thoughts trying to press out the bubbles with one’s finger only tends to make the liquid more fizzy and the bubbles more active! It is a far better strategy to acknowledge the bubbles, allow them to be in one’s awareness to some extent, but letting the bubbles go flat over a period of time, perhaps whilst steering one’s attention elsewhere by engaging in some distracting activity.
The core feature of psychological treatments that work most reliably in the long run is that they help people to tolerate anxiety rather than to eliminate it. Paradoxically, people commonly experience more success at reducing anxiety when they allow some anxiety to be there rather than aiming to get rid of it. This is easier said than done. Especially for more severe forms of the disorder, there is commonly an advantage of combining psychological interventions with the use of prescribed medication. Psychological interventions commonly have a strong behavioural focus. They commonly involve people using strategies to not engage in neutralizing rituals even when feeling anxious in response to an obsessional thought or compulsive urge. By resisting the impulse to respond in the usual way, the impulsive urge tends to reduce. In time, the anxiety tends to reduce as well. Later still, the obsessional thoughts or images tend to become less frequent and persistent. This process is called Exposure and Response Prevention (ERP) and is described in detail below following a description of brain processes involved in OCD.
Brain Lock (How the brain works in OCD)
In his fascinating book, The Brain that Changes Itself, Norman Doidge describes a process involving three areas of the brain which contribute to OCD behaviour. We can all be prone to intrusive thoughts (e.g. did I lock the car door?), but in OCD reactions an individual tends to “lock on” to the worry rather than to dismiss it. When we make a mistake, we are likely to get a “mistake feeling” which is mediated by the orbital frontal cortex. Obsessional thoughts are typically accompanied by such a feeling. This “mistake feeling” is accompanied by an increase in anxiety which further prompts us to correct the situation, a process mediated by the cingulate gyrus. Once the mistake has been corrected, both the mistake feeling and the anxiety disappear, and we can then readily move on from that situation. This process of letting go of the “mistake feeling” and being ready to move on is mediated by the caudate nucleus which acts as a kind of “automatic gear shift”. As a result of abnormal activity in these brain structures, the OCD sufferer is more prone to the “mistake feeling” arising, more anxious when it occurs and less able to shift or move on from the situation. In a sense the experience can be like reading a book to the bottom of a page but not being able to turn the page. Using this knowledge and awareness of “brain lock” it is possible to compensate by developing a form of “manual gear shift” to move on from the situation. The best form of “manual gear shift”, or the best way to “turn the page”, is to engage in some other activity, and especially one which is readily accessible and enjoyable.
When we act on old habits we strengthen those habits, in part by reinforcing connections between brain fibres which support the link between one behaviour or reaction and another. If we engage in any repeated pattern or ritual it will tend to become stronger and more automatic, as though we are deepening a well-worn groove. However, if we desist from a habitual connection between one behaviour or reaction and another, the link between them will tend to become weaker. When we deliberately engage in an alternative action this helps develop a different “groove” or habit pathway to follow. We now know that we form new brain connections which influence our behaviour when we react in novel ways. Therefore, by using a “manual gear shift” to discontinue a ritualistic behaviour and engage in another activity instead we can literally rewire our brains. One OCD sufferer used this awareness to deal with a difficulty repetitively checking her front door lock when leaving her house. She practised very deliberately checking the door lock just once, and then turning around and walking directly to her front gate. She saw in her mind’s eye the new brain connections she was developing to inhibit the old pathway and to promote the new one (immediately walking to the gate). After doing this for some weeks she one day found herself absent-mindedly checking the front door lock several times. As soon as she noticed this she immediately said to herself, “Wrong groove!” and straight away turned to walk off. She was then successful in desisting from the old ritual with minimal lapses.
For at least mild to moderate levels of OCD symptoms, it is worth using the alternative action strategy to deal with “brain lock” as described above, shifting to an activity which is enjoyable, productive or distracting. For more severe or persistent patterns of OCD, it is commonly necessary to use a more intensive treatment approach, Exposure and Response Prevention (ERP), described below. The more severe or persistent the symptoms, the more value might be gained by combining psychological treatment strategies with prescribed medication.
Exposure and Response Prevention (ERP)
Exposure strategies involve the person actively and deliberately facing an anxiety-provoking situation whilst refraining from attempts to reduce one’s anxiety through escape or avoidance. Response prevention means that when the person faces a situation which triggers their OCD response (e.g. excessive handwashing in response to a sense of contamination), they deliberately refrain from engaging in the usual compulsive behaviour. For example, if a person was going to use the Exposure and Response Prevention (ERP) strategy in relation to fears of becoming severely ill from contamination, they might repeatedly expose themselves to situations involving dirt and germs (e.g. rubbing their hands on the carpet, touching a soiled object, or using a public toilet) without washing their hands at all for an extended period. If they feared that sensing a bump in the road whilst driving might mean that they have unwittingly run someone over, they would refrain from turning around and going back to see whether there were signs of an accident. If they went through a counting ritual as a compulsive mental act whilst in a particular stressful situation, they would aim to endure the discomfort without engaging in such counting. Again, this is easier said than done. This is because the anxiety reactions associated with OCD are associated with instinctive survival reactions (fight and flight response) which are designed to impel us to retreat from danger or remove the sense of threat. As unreasonable as obsessive-compulsive behaviours might seem, if a person really felt that they might have just run over someone, or that their house might be about to be burgled or burnt down, or that they or their loved ones might become severely ill or die unless some specific compulsive urge were acted upon, it would understandably be terribly difficult not to act on that urge, especially at first. For a person to desist from acting on the compulsive urge, they would then need to “do nothing” and surrender to the prospect of some calamity actually occurring. Fortunately, what often happens when someone faces their fear in such a manner, their level of fear initially tends to go up, but then it levels off, and eventually it comes down. This is somewhat like surfing a wave of anxiety. It may take an hour or more in many situations for the anxiety to subside, especially if someone is testing themselves with more challenging situations. This experience helps develop one’s capacity to manage subsequent waves which may then become less fearsome. The key to managing this process is to aim to tolerate the anxiety as opposed to attempting to escape, eliminate or otherwise control it. It works best when the person allows some anxiety to be there, observes their anxiety levels over time with at least some level of detachment and recognizes when the anxiety has started to come down.
This is the same sequence which commonly follows a person exposing themselves to any phobic situation, meaning facing any situation which involves a markedly exaggerated fear. In time, the person adapts to the anxiety being there, gradually gets used to the notion that their worst fears are not in fact eventuating, and starts to notice their anxiety level coming down in a process known as “desensitisation” or “habituation”. If the person then acknowledges that they have been able to bear with their fear, albeit with considerable trepidation and discomfort, they will typically experience a greater sense of “self-efficacy”, or confidence in their capacity to face the challenging situation without resorting to their OCD rituals in their previous usual manner.
Developing further understanding of ERP strategies (when yet to be convinced!)
In his book, OCD Treatment Through Storytelling, Allen Weg describes a number of analogies which promote further understanding of ERP strategies for OCD including his “Bee Trap” story. It is possible to make a bee trap by putting some honey at the base of a clear plastic drink bottle and then suspending the bottle upside down with the lower third of it wrapped in dark tape: the lower taped part of the inverted bottle near the small opening screens out light. Bees will enter the bottle at the opening from below to get at the honey. However, when they have had their fill of honey and seek to leave, they get stuck in the upper, light-filled part of the bottle and find themselves unable to escape. This is because bees are programmed to fly toward the light owing to strong instinctual survival tendencies. They do not understand plastic or glass! They don’t realize that the only route to escape is to fly down below into the darkness. It is as though every fibre of their being (or bee-ing!) tells them not to go in the very direction that could lead to their freedom. In a way, so it is with OCD sufferers. The most reliable route to ultimate freedom is to head “into the darkness” by facing the dreaded fear. Their survival instincts, based on acute anxiety being triggered (the fight-flight response) tell them to go in the opposite direction to the actual escape route in order to avoid perceived danger. However, as OCD sufferers gain more experience, and confidence, at heading into the felt darkness of directly facing their fears whilst resisting rituals, they are practising the most reliable means of gaining relative freedom.
Another story especially relevant for children is that the OCD is like a bully at school. If a younger boy were to give in to a bigger and aggressive bully who threatens him to do things for him (e.g. line up in the tuckshop to buy his lunch), the bully’s demands are not likely to decrease by doing his bidding. Indeed, the more that one gives in to a bully, the more their demands are likely to escalate: this increases one’s fear whilst further diminishing one’s sense of freedom. Ultimately, as frightening as it might be, there can be much gained by confronting the bully or refusing to give in, perhaps aided by support of others in authority, such as one’s parents and a teacher. Similarly, OCD reactions tend to recede as the child faces their fear, perhaps strengthened with the moral support of their parents and assisted by someone in authority (e.g. a therapist) who is aware of specific strategies to tackle the OCD.
Photograph: Mitch Lensink
Additional ERP Tips
In psychological therapy, ERP strategies typically work best when the person works out a hierarchy of challenging situations with their therapist from the least threatening to the most threatening. For example, with OCD based on fears of contamination the person might initially touch the carpet and wait five minutes before washing their hands, and eventually face more challenging situations such as touching a soiled object before making a sandwich and eating it without washing one’s hands. ERP practice exercises tend to have most impact when they are repeated and prolonged. Practice can be structured and planned, but compulsive urges are also weakened by seeing their occurrence as an opportunity to practice resisting them. Resisting acting on a compulsive urge is especially assisted by engaging in another distracting activity as soon as the urge arises. Distress levels in each challenging situation tend to reduce with repeated practice, but not necessarily in a consistent way so it is important to be patient with the process. If the client feels unable to resist a compulsive ritual in a challenging situation, it can still help to at least delay engaging in the ritual, or to perform it in a different manner to usual (e.g. responding to an urge to move objects by using the opposite hand to usual, or placing them in a different order). Sometimes it may help to repeat a mantra (e.g. “Move On!”, or “I can get through this”) when resisting a compulsion. The therapist and client can collaborate to plan exposure-based exercises in a structured way. This typically involves repeated “experiments” in which the client’s level of distress and “self-efficacy” in a range of situations are recorded across time. This monitoring can be important, as people with OCD engaged in ERP-based therapy may not fully recognize the progress they are making, especially when it might be quite slow and gradual and accompanied by feelings of significant distress.
Experiments to help counter OCD reactions
In psychological therapy clients are encouraged to conduct experiments to learn more about their OCD reactions and ways of curtailing them. One example includes alternating “control” and “non-control” days. On a “control” day, the person will use their usual counting or washing rituals, etc, in their usual attempts to reduce their OCD-related anxiety. On “non-control” days the person can trial just being aware of obsessive-compulsive urges, and then “do nothing” in response to them, allowing the anxiety to be there. People may be surprised by the extent to which their overall anxiety tends to be lesser on “non-control” days. If a person fears that certain OCD thought patterns might make them “go mad”, they could deliberately attempt to induce insanity by thinking in the most disturbing way imaginable. This ultimately tends to reduce the fear as the person recognizes that they have not lost their mind, despite perhaps continuing to feel some anxiety. If a person fears certain thoughts will bring about a disaster (e.g. harm befalling family members), they can deliberately try to make such feared outcomes happen. Such an exercise might be initially frightening, but it can help reduce the sense that we might cause severe harm just by thinking certain thoughts. In particular, experiments can include observing what happens to heightened anxiety levels over time when facing challenging situations and desisting from rituals.
Suggestions for Family Members
OCD impacts not only on the sufferer but also can be very disruptive to family members owing to its impact on everyday life routines. In the first instance, it helps for family members to understand the nature of obsessive-compulsive reactions and to have a sense of the degree of subjective struggle faced by their loved one. It helps to think of the OCD as an external nuisance that acts on and through their family member, and to separate the OCD from the person themselves. Using logic or reason in an attempt to convince their loved one of the folly of their rituals tends to lead to frustration all round: OCD behaviours develop out of the overactive triggering of anxiety-based instinctual survival strategies which are designed to prolong the life of the individual and the survival of the species. They are very powerful reactions which, once triggered, cannot be readily debated into submission! In order to reverse such over-reactive survival-type responses in OCD situations the key is for the OCD sufferer to gradually develop confidence that they can resist their OCD rituals without dire consequences through the application of such strategies as the ERP techniques described above.
Therefore it helps if family members resist making harsh judgments or having rigid expectations about the OCD sufferer’s behaviour, however inconvenient or frustrating. By the same token, it is also important to not overcompensate for the OCD behaviour or to adapt to the rituals to the point where ongoing OCD behaviour is unwittingly supported. Any ways of reducing or limiting heightened stress levels in the home setting can help, apart from unduly giving in to the OCD rituals. In practice, family members might best aim to strike a balance between understanding and supporting their family member with OCD whilst not overly adapting to OCD rituals, joining with their loved one in seeing the OCD reactions themselves as the external culprit in disrupting home and family life rather than the person themselves.
For parents in particular, it is important to maintain strategies to reduce one’s own stress levels and to pursue enjoyable recreational activities, preferably including separate positive experiences as a couple to support that primary relationship within the family. Parents are at times inclined to take excessive responsibility for some of their children’s afflictions, but guilt trips won’t help. Recognizing your child’s constructive efforts to tackle OCD reactions does help, as does recognizing even subtle signs of positive change. Especially when your child’s OCD reactions are severe, it helps to be very patient in allowing for longer term change punctuated by frequent lapses, especially during periods of increased stress. Finally, it helps to counter attitudes and beliefs which may contribute to obsessive-compulsive tendencies as outlined below.
Concluding thoughts
The most successful ways of alleviating persistent and excessive anxiety reactions tend to involve tolerating the anxiety as opposed to eliminating or controlling it. Successful strategies tend to have more a quality of “letting go” in a fashion. These strategies may be supported by mindful awareness of how one is making genuine progress in spite of the discomfort and inevitable lapses along the way. Persistence pays off. Progress in managing OCD leads more to satisfaction in curbing restrictive rituals and a greater sense of choice in one’s behaviour rather than freedom from discomfort.