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My thoughts on OCD

How I think about obsessive compulsive disorders

· Psychotherapy

OCD (Obsessive Compulsive Disorder) is a topic I often work with in therapy. People who suffer from compulsive behaviours, begin therapy saying: ‘This is taking over too much of my time’. The time is also a major factor in determining the strength and power of the OCD.

The disorder is defined by the DSM-5 in black and white terms, however, I prefer to see it as a spectrum. OCD is often associated with anxiety. If we compare it to GAD or worry, OCD can equally occupy a lot of our time. In my experience, the main factor affecting the severity of the compulsion is: ‘how much does it get in the way of your day-to-day functioning?’. This is also what makes a difference for the people who finally seek help: they often find themselves severely restricted by the compulsions

Magic and Rituals

I often think about when we are children and we walk on the pavement avoiding the cracks, or not touching the lines. Those games we play are somehow similar to OCD - The person who display OCD-type behaviour often has some ritual or routiney way of doing things.

Most common OCD behaviours are counting, washing our hands, checking (doors and windows), putting things in a certain order and so on.
When I ask my clients what makes the ritual so essential, sometimes they find it hard to say. It can take sometimes to verbalise and make sense of a routine behaviour that has become so ingrained in our life.

There is something magical that needs to be uncovered: there is usually an association that needs to be made explicit. Something like: ‘If I don't do this 7 times every evening, something bad is gonna happen to my family’

Other times, when the OCD appears together with agoraphobia, the client might come to the conclusion that they feel safe for the activity of checking and not necessarily for what they are checking. E.g. ‘I feel safe because I am checking the doors in a certain order; not necessarily because the doors are shut’.

In any case the client attributes to compulsive behaviour some sort of ‘magic’ power: the repetition will keep me safe.

What gets repeated is often a behaviour, but it can also be a thought. For example counting or praying.

Breaking the spell

During the course of therapy the client comes to the realisation that there is an association between the thought that ‘Something bad is gonna happen’ and the checking behaviour. As soon as this happens, the spell is broken and the power of the ritual diminishes.

When the spell is broken, the person is left without the neutralising behaviour that held them safe. In this phase the client usually feels more vulnerable and can be exposed to more anxiety.

In my experience as a therapist, every OCD behaviour is worse when the client is on their own. The client can usually let go of the ritual when there is another person around. When I ask my client what is good about the other person being there, they often reply that they can share the responsibility for safety with someone.

The dichotomy seems to be control-responsibility or even safety-responsibility.

Experiments

At this point the client has evolved a certain level of self-awareness and developed a meta-perspective (i.e. the ability to think about the way they think). With this in mind they become aware that the behaviour can be questioned or even challenged. Behavioural changes are difficult and can take a lot of time and effort. Often I asked my clients to rate their anxiety and design for them a series of experiments. What would happen if you don't check? What would happen if you stay with that anxiety? We often overestimate the effects of anxiety. We need to give ourselves the chance to survive that uncertainty. This requires a lot of courage and therefore it is usually a good idea to seek support. Over time we can create a series of instances that demonstrate to ourselves that we can survive the anxiety without the ritual. Clearly behavioural-oriented therapies have a good and effective structure for this (for example CBT and DBT, but also Gestalt).

Time and creativity

The outcomes of the work on OCD is different for every client; but they all come to the realisation that the ritual is no longer necessary and they can use their time more effectively. Reclaiming control over our time is important and can be very empowering. The neutralising behaviour can be addressed and challenged with behavioural experiments with the intent of diminishing the power of anxiety.

It is difficult to break through a routine, but our time belongs to us, so we need to live in it to the fullest. I believe that being in the here-and-now is the antidote to anxiety and it can help us to live a more creative life.

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