You’ve been diagnosed with OCD and know you want to get better. What does treatment look like?
The treatment of choice for OCD is Cognitive Behavioral Therapy, or CBT for short. CBT assumes that our thoughts, feelings, and behaviors are all linked. I’ll describe a situation that occurred about 10 years ago to illustrate this interaction between thoughts, feelings, and behaviors. I went on a run in my hometown one summer evening. All was well until I turned a corner, and there stood two bobcats in the middle of the trail. I realized there was danger and experienced fear that activated my fight, flight or freeze response. I’ve never really planned for the appropriate response to encountering bobcats on a trail before, but I stopped moving, very slowly and quietly stepped off of the gravel path and onto the grass where my steps would make less noise, backed away slowly, turned the corner, and ran faster than I’ve run anytime since. My response seemed immediate, but there were three important components involved in this example including thoughts, feelings, and behavior. In this example, my interpretation of the situation as dangerous was appropriate and prompted necessary action for my safety. I learned that backing away slowly and then hightailing it out of there kept me safe, and I’d probably do exactly the same thing if I came upon bobcats again.
What if my brain started tricking me into believing that situations that actually pose little risk are very dangerous? If I was out on my run and turned the corner to see two puppies and interpreted them as dangerous, I would have experienced fear, and my fight, flight, or freeze response would have been activated, resulting in me running away from the puppies. I would have gotten back to my car safely and assumed that the reason I survived was because I avoided the puppies. I’d think to myself, “Whew, that was close. Better be prepared next time. At least now I know that I’ll be safe if I get away from the puppies.” Yes, I stayed safe in this second example. But was it really because I avoided the puppies? Or would I still have been safe if I had walked right past the puppies?
Anxiety is a good and helpful emotion. It prompts physical responses that prepare us to fight, flee, or freeze in response to danger, allowing humans to survive for centuries. Without it, we’d snuggle with rattlesnakes and tarantulas, drive 90 miles an hour around sharp curves, and jump from the roof with a sheet as a parachute. Anxiety is that voice that makes us ask, “Is this really a good idea?” so that we can survive as a species. OCD tells you that things that are not really dangerous are very dangerous, like the example above with the puppies. In these situations, we have to reverse the interaction between thoughts, feelings, and behaviors to break the fear of puppies that causes us to avoid activities that we might otherwise enjoy.
Cognitive behavioral therapy for OCD often involves Exposure with Response Prevention, or ERP for short. We expose ourselves to the thing that scares us (puppies), allow our anxiety to go up or down on its own, and learn some new ways of thinking. If I always avoid puppies, I never learn that they really aren’t vicious. But when I spend time with them, I gather new evidence that they’re really not as dangerous as I thought. This allows me to do some things that I was missing out on before, like going to the park where lots of dogs are out playing.
A common obsession is with getting sick. You might think, “if I touch those doorknobs and don’t wash my hands, I’ll get so sick that I’ll have to go to the hospital.” This thought creates anxiety and fear and, naturally, you avoid touching doorknobs. You might wash your hands a lot, use barriers like paper towels to open doors, and carry sanitizer with you. OCD tells you that these steps prevented you from getting sick, causing you to feel more comfortable, and reinforces these behaviors. This pattern might increase over time so that you feel like you can’t open a door without wearing gloves or even have other people open doors for you, and your life gets really restricted. The same sort of thing happens with all kinds of obsessions, and you have to do a lot of things to make you feel safe. In therapy world, we call those things that you do to decrease your anxiety and try to feel safe “rituals” or “compulsions.” Over time, rituals stop making you feel so safe, and you have to do progressively more and more extreme things for protection. Rituals make you feel better for a short time, but you really just feel more and more anxious over time. The places you can go and things you can do become restricted, and you end up missing out on a lot of experiences.
People have probably told you that there’s nothing to worry about, promised you that there’s no danger, but that hasn’t helped much. Maybe they’ve told you to stop feeling anxious, and you really wish it was that simple. This is why some people say that traditional talk therapy didn’t help them and actually may have reinforced their symptoms. In CBT, we reverse the pattern of avoiding things that make us anxious. Over time, we start to feel less threatened by these things, and it allows us to do more and more things that we thought were dangerous.