OCD refers to obsessive compulsive thoughts and behaviour. These can include obsessive thoughts around four types of vulnerabilities which are: 1) health and illness, 2) danger, 3) poverty and 4) losing control. Specifically, we can think obsessively about sex, death, relationships and contamination, amongst others. We may behave compulsively by cleaning, checking and double-checking or repeatedly asking our partner the same question. We also tend to avoid certain situations which make us feel particularly anxious. On a physical level, it is common to experience a tightness in our chests, shallow breathing, sweaty palms, palpitations, dizziness or brain fog when in the grips of obsessive and compulsive thoughts and behaviours. We may also generally feel low in mood, lonely, empty and tired because of our condition.
Underlying the specific nature of the thoughts and behavour is the ‘what if’ question. For example, ‘what if I didn’t lock the door on my way out?’ Or, ‘what if the food I am eating is contaminated?’ Or, ‘what if I picked up the knife and tried to stab someone else (or myself) and what if this means that I am going crazy? In his highly acclaimed book, ‘Freedom from Obsessive-Compulsive Disorder: A Personalised Recovery Program for Living with Uncertainty, Dr Jonathan Grayson explains that regardless of what the specific nature of the OCD is, the bottom line is the difficulty living with uncertainty. He goes on to say that whilst we all struggle with uncertainty to an extent, particularly around the existential uncertainties in life such as birth, death, life changes etc., those with OCD find uncertainty and the resulting anxiety, particularly difficult to manage. This is at the core of the disorder, regardless of the specific thoughts and behaviours. Indeed, it is common for the nature of the OCD to change over a lifetime. One might start with obsessive thoughts about killing oneself or another and then move on to obsessive thoughts about whether we really love our partner. It is common for OCD symptoms to disappear for months to years or to at least subside and feel more manageable and then to reappear or worsen at life transitions such as graduation, changing profession, getting married, having children or retiring. We can imagine the present subject or subjects of our OCD as the current actors on the stage whilst the difficulty with uncertainty, the backdrop to the scene, remains the same. The scenes and the actors come and go but it is the backdrop, the difficultly with uncertainty which does not change. I use this metaphor because in terms of treatment it can feel tempting to want to ‘talk out’ the OCD. Often this might lead to feeling better temporarily, however since the underlying issue is around uncertainty and no therapist can give us 100% assurance on a ‘what if’ question, it is far more fruitful initially to focus on the difficulty with uncertainty.
Why do some individuals find uncertainty so difficult?
Clinical research shows that there can be neurological differences in some OCD sufferers. To simplify greatly, this means that there are some neural pathways going from the orbital frontal cortex to the cingulate gyrus, to the thalamus and back to the orbital frontal cortexwhich act as a negative feedback loop. See this explanation from the BBC http://www.bbc.co.uk/science/humanbody/mind/articles/disorders/causesofocd.shtml
These parts of the brain are responsible for OCD like behaviour. When one of these parts is not working properly then we can have OCD symptoms. Other research suggests that OCD is linked to a low level of serotonin. For this reason it is worthwhile considering the option of taking an SSRI or anti-anxiety medication, particularly if therapy alone does not help or if there is also low mood, dysthymia or depression. In my experience, clients are often wary of becoming reliant or medication or think that they should be able to ’sort their problems out on their own’. I suggest that taking medication should be discussed with a psychiatrist but can been viewed as an additional support. Sometimes we feel too overwhelmed with our OCD symptoms to be able to engage in therapy. In these cases, medication can help take the edge off, particularly since starting therapy can sometimes temporarily increase our anxiety and worsen our symptoms. However in my clinical experience, whilst medication can improve symptoms, it is not enough to stop them and this is why therapy is also necessary.
What is the treatment for OCD?
Exploration of Adverse Childhood Experiences
Whilst some argue that OCD is purely a biological matter, I have found that all OCD clients have experienced significant circumstances in their childhood where there was a backdrop of uncertainty and a feeling of not being in control. Sometimes it takes bit of exploration to identify this. Many of us feel very protective of our parents. We might feel guilty exploring childhood difficulties with a therapist, as if we are betraying our parents. It is also fairly common not to remember too much about our childhood or to emphasise how we were so lucky and had such a good childhood. The fact is that however good our childhood was, we all experienced some hurts, upsets, minor traumas or full-blown trauma along the way. This is simply because our parents are human and no human is perfect. Even the most well -meaning parents may have unintentionally negatively impacted their child or children. Whether it is because they parented in the same way as they were parented so thought that their behaviour was normal. Or because they were not fully available to their child due to overworking, depression, alcoholism or OCD, amongst others. In fact it is common for an OCD sufferer to have a parent who also struggles. Sometimes the parental wounding can simply be because you have different temperaments. For example, an outgoing mother with a shy introverted child might unintentionally wound the child when she insists that they sing in front of the whole family at every family gathering.
A common theme in childhood experience of OCD sufferers is having felt ‘not good enough’ or insignificant. Perhaps there was conflict in the marital home and the child was not given the attention they needed. Perhaps one had to compete with other siblings who demanded more of our parents’ attention due to special needs. Maybe we were bullied at school and didn’t tell anyone so didn’t get the support we needed. Perhaps we had a parent with a volatile temper and felt as if we were constantly living on egg shells. We might at times have felt alone, insignificant and lacking the reassurance and empathy we needed from one of our key care givers. Dr Jeffrey Young created Schema Therapy which is an effective tool for uncovering childhood situations which have left an unhealthy mark on our psyche. Schema Therapy also provides a treatment model for how to heal these schema. Schema is the name coined to refer tothe particular type of difficult childhood circumstances we experienced that still impact us in an unhelpful way today. These do not need to be ‘ Big T’ traumas. Often ongoing and seemly low-grade traumas such as a parent being preoccupied with depression can have just as damaging an effect. There are around 18 different schema and the one which relates to OCD is the Vulnerability to Harm and Illness schema.
Gestalt therapy posits that anxiety is the feeling of excitement when we are not allowing ourselves to fully breathe. The Gestalt definition of excitement refers to the whole range of outward going and forceful e-motions including not only excitement but all types of anger from feeling irked, irritated, annoyed, frustrated, angry, enraged, hateful, spiteful, malicious, vindictive and murderous, to name but a few. In my experience, clients with OCD often have a difficult relationship with anger. They believe that anger is a ‘bad’ emotion and that it is unhealthy. They may try to bypass their anger. Either we don't feel anger at all or we bottle it up or get angry with ‘the world’, current affairs or public transport services, for example. We find it difficult to own and express anger assertively and directly to another, usually a significant other. We might be passive-aggressive or deflect our anger by getting irate with the shopkeeper who short-changed us rather than our partner who pissed us off. We fear that expressing anger directly is risky and that we may end up losing the person we love if we do so. We have normally learned early in our childhood that getting angry is risky. We may instead internalise our angry feelings and become angry with ourselves. A common denominator in all OCD clients I have worked with is the very critical inner voice. Often clients are accompanied by a constant narrative about just how terrible, incompetent or ridiculous they are for having OCD symptoms. They blame and get frustrated with themselves. This then causes us to feel even worse about ourselves and never resolves our OCD. Therefore an important part of therapy is exploring how we learned that expressing anger was risky, how we can learn to express it appropriately, and how we can develop a more compassionate voice to ourselves. Often this includes experiential work where we look at where the misplaced anger really belongs and where we fight back against the original person who made us feel bad as a child.
This is clinically proven to be effective in the treatment of OCD. It is premised on the idea that our thoughts affect our feelings which then affect our behaviours. For example a thought such as ‘what if I were to pick up that knife and cut my wrists?’ leads to a feeling of anxiety and a behaviour of eliminating all knives from the house. If we can challenge our thought and replace it with something more helpful then we don’t feel anxious and we are ok with knives in the house. Challenging the thoughts and beliefs entails firstly logging them to see what kind of unhelpful inner talk we have, and then analysing them for cognitive distortions such as catastrophic thinking, ‘black and white thinking’, fortune telling, amongst others. See this link for a full list and explanation of thinking errors. We also look for the evidence to suggest our thought has significance. For example is there any evidence which supports the idea I might cut my wrists? Have I ever done that before? Probably not. The second part of CBT is the behavioural part where we start to expose ourselves to situations and thoughts that are difficult for us until they no longer affect us. For example we tolerate eating with a fork that might be contaminated and when we do it enough times, we realise we can handle the uncertainty and the anxiety that accompanies it and it is no longer a big deal for us.
To oversimplify, this is holding the knowing that all our experiences are temporary and often momentary. By reframing how we view our symptoms, we give them less power. For example, think about how different it feels to say to yourself, ‘In this moment I am feeling anxious’ or ‘right now i am having a thought that the spoon may be contaminated’ rather than simply focussing on how anxious you feel or how dirty the spoon might be. Mindfulness Based Cognitive Therapy (MBCT) has also been clinically proven to be effective for working with mental health disorders including depression and OCD. A great resource to learn more about mindfulness is Tara Brach's website.
Dr Pat Ogden, co-author of Sensorimotor Therapy offers an alternative to the CBT approach. The idea is that we can alter the faulty neural pathways that lead to OCD and anxiety by introducing somatic interventions. Dr Ogden describes the building blocks of experience which include 1)our thoughts, 2)emotions, 3)body sensations, 4) movements and 5) remembered images, smells or sounds that may come to mind as we focus on these. If we can change one of the building blocks in our well-trodden neural path then we can break the path and behave differently. This might mean having the ‘what if’ thought but not allowing it to take hold. One of the ways we can break the old pattern is by working directly with our bodies. For example making the opposite movement that our body wants to make when we are feeling anxious such as lowering our shoulders and standing straight rather than raising our shoulders and hunching over. Somatic interventions are also offered for the client to try which help to reduce anxiety. Learning techniques to master anxiety gives us a sense of mastery and can give us the confidence to engage in the next steps of therapy.
I believe that having expertise of all these approaches means that the client and I have a highly equipped tool box for tackling OCD. Some clients are ready to get started with CBT straight away and others find this more difficult in which case we may start with exploring key schema, mindfulness and anxiety management techniques until they feel ready to start CBT. Others respond well to the benefits of a containing and nurturing therapeutic relationship and a Gestalt Therapy approach.