A client from Japan shared this comic with me. As you can see, it's all in Japanese and I'm told it's from a blog written by an individual with OCD. Even without any understanding of the text, the scenes depicted in these images should look familiar!
Fear is a useful emotion. It keeps us safe and prepares us to take action when we're in danger. Fear has been an integral part of our survival as a species - we all feel it. We generally start to label fear as 'anxiety' when it is disproportionate to actual risk; when our brains activate our 'fear system' without the presence of an actual threat. Every individual is different - we all have unique cues and triggers which set off this system, but make no mistake: we all have it and we all feel it, regardless of the actual presence or absence of a threat.
Most of us have the luxury of being able to avoid our fears. If I have a fear of sharks, for instance, I can live a full and meaningful life without ever having to confront that fear. Provided I didn't have any ambitions of being a sailor or professional surfer, I can probably live my day-to-day life without ever seeing any repercussions of my shark fear.
Individuals with OCD do not have this luxury. Obsessions are pervasive and all-encompassing. For someone with OCD, living a life in which you avoid your fears would be incredibly limiting and even debilitating. These individuals have no choice but to confront their fears.
Sometimes individuals with OCD can feel shame about their exposures. The thought of "I should be able to do this" can be hard to shake. I recently worked with an individual who needed to perform counting rituals when tying her shoes - the prospect of resisting these rituals was daunting and she felt a great deal of embarrassment that this simple task was so difficult for her. I reminded her that her brain does not discriminate between rational and irrational fear when it sets off her fear system. Fear is fear, whether rational or irrational. It's the same internal experience; the same system activated by your brain. If we saw someone with a shark phobia decide to confront their fears and get into a shark cage, we'd say "Wow! That's incredible!", and yet, with OCD, we often forget these experiences are the same. Resisting counting rituals while tying your shoes can evoke the same internal experience as someone face-to-face with a shark. It's important that we acknowledge just how badass exposure therapy is. ERP is not a therapy for the weak or timid; it's for courageous individuals who choose to confront their fears. While most people are coasting through life without ever having to confront their greatest fears, individuals with OCD are facing these challenges head-on, every day. That's badass.
The Haunting of Lindsey Jacobellis, published in today's New York Times, touches on a principle instantly familiar to anyone who has struggled with obsessive bad thoughts: thought suppression does not work. Lindsey Jacobellis, an Olympic snow boarder most noted for a blunder which cost her a gold medal in 2006, has finally adopted a new approach to unwanted thoughts - accept them. Rather than trying to escape the constant reminders of past performance mistakes, she makes room for the thoughts and embraces the fear that comes with them. Believe it or not, this approach is an outlier for many performance coaches, who often encourage athletes to focus on good thoughts, rather than acknowledging the bad.
Another year, another amazing OCD conference. I am always so proud to be a part of this wonderful community. This year I was fortunate to be the affiliate representative for OCD North Carolina and, for the third consecutive year, I facilitated a support group for parents of adult children suffering with OCD. As usual, I am floored by the resiliency of the OCD sufferers that I meet and inspired by the dedication of the researchers and clinicians who work tirelessly towards better treatment outcomes.
Hockey fans will know that one of the most exciting moments in a game of hockey comes at the end of the game, with one team hopelessly trailing. In the expiring moments of the game, the trailing team will often pull their goalie. It's a huge risk - the goal is undefended - but at this moment of the game, there is nothing to lose. The trailing team will not win by playing defense; they must play offense. And so, they bring an additional player onto offense and hope against hope that they can score (this does actually work, by the way).
OCD hopes that you never think to pull the goalie. It depends on you always playing defense - responding to fear, discomfort, uncertainty. OCD says 'jump' and you oblige. As long as you play by these rules, you can never win. The odds are always, always in favor of OCD. If you want the odds back in your favor, you have to pull the goalie and go on offense. When OCD says "your hands are dirty", you don't wash them; you get them dirtier. The risk is greater; it's scarier. But we know exactly what happens when you play by OCD's rules. If you choose to go on offense, you give yourself a shot.
It seems that a week doesn’t go by without hearing one of these phrases (or some similar variation) from my clients:
My mom said that she would shower after being in a crowded bar, too.
My friend said that it’s normal to double-check that the car is locked.
My girlfriend told me that she would also be grossed out by touching a toilet seat.
These kinds of phrases can serve many functions. They can be hopeful pleas to avoid adding yet another behavior to the long list of compulsions to be targeted in treatment. Or perhaps they are a furtive attempt to engage in a compulsion under the guise of something else, a sneaky tactic employed by a sufferer who is not yet ready to confront OCD. Maybe these phrases are the work of the OCD itself – convincing the sufferer that they should bend to its wishes without delay. Or maybe, they are a last-ditch effort to find some semblance of normalcy in an otherwise chaotic and uncertain world. Perhaps they are even accurate assessments of what an ‘average’ person might do.
When my clients bring one of these phrases into session, I invariably offer the same response: I don’t care. It doesn’t matter.
These are words that are not heard too frequently in therapists’ offices (hopefully), but in this particular instance, I stand by them and believe them. It’s not that I don’t care about the client or empathize with the distress that they find themselves in; it’s simply that the concept of “normal” is utterly irrelevant to the treatment of their OCD.
Do individuals with OCD engage in behaviors that might be considered abnormal or excessive? Of course. In fact, behaviors which are “clearly excessive” are described in the DSM-V diagnostic criteria under its definition of the term compulsion.
But here’s the real question: is excessiveness (or normality) the sole component to determining if a particular behavior is compulsive? Absolutely not.
The DSM-V offers some additional guidelines under its diagnostic criteria, one of them being that compulsions “are aimed at preventing or reducing anxiety or distress”. That is to say that it is not simply the frequency with which someone engages in a behavior, but also the function of the behavior itself. Is that behavior a means of modulating an unwanted emotion? Does it reduce anxiety? Does it prevent a person from having to experience anxiety? If you can answer yes to these questions, you have yourself a compulsion.
Let’s revisit the toilet seat example above. As a practitioner who guides clients through Exposure and Response Prevention, I have a certain familiarity with toilets. For those unacquainted with this treatment modality, ERP is an evidence-based practice which falls under the umbrella of Cognitive Behavioral Therapy (CBT). It is a process by which individuals with OCD expose themselves to triggers, evoke anxiety, and then practice allowing that anxiety to run its course without altering it in any way. By doing this, we allow our brain to have a corrective experience, showing our brain that it does not need to do anything (read: compulsions not necessary!) in order to get through the experience of anxiety. For individuals with contamination obsessions, I often find myself in the bathroom touching toilets. Let’s ponder a few questions:
Do I enjoy touching toilets? No.
Is rubbing a toilet and then rubbing my clothing and body a “normal” thing to do? I don’t think so.
Would I rather not be touching a toilet? Yeah, probably.
Does this experience spike my anxiety? NO.
Aha! This is the important part! It doesn’t matter if your friend, your mom, or everyone on your basketball team avoids touching toilets. Chances are, these people are not touching toilets because it’s maybe a little unpleasant or because they have no reason to rub all over a toilet (unless your friend is an OCD therapist)…but if you have OCD and your anxiety is the reason for your avoidance – that’s a compulsion. It does not matter if the behavior is considered normal or abnormal; if the function of the behavior is to reduce or prevent anxiety, that is a compulsion. If you are an OCD sufferer, your barometer of compulsive behavior is not normality or the behavior of others, but rather, the barometer is your anxiety itself. If you’re truly interested in stamping out your OCD symptoms, forget ‘normal’ and let your anxiety be your guide.