Obsessions and compulsions are pretty dramatic names for things almost every person experiences at some point. If you’ve ever had a thought you just couldn’t get out of your head, that’s more or less an obsession. Likewise, if you ever felt you needed to go check on your stovetop (despite pretty much knowing you shut off the burner) or had a little good luck ritual that you had to do to feel right, that’s a compulsion. However, for people with obsessive-compulsive disorder (OCD), these experiences become more than minor nuisances and/or negligible quirks; they are persistent, distressing, and disruptive occurrences. The onset of OCD can be extremely upsetting and confusing. Many people looking for help don’t know where to start or even what “help” would look like. In this article, we’ll explore some of the therapeutic options for OCD and what getting better looks like.
Exposure Therapy OCD is generally treated with psychotherapy and/or medication (prescribed by a physician). The favored form of therapy for OCD is exposure-and-response prevention (ERP). When someone chooses to engage in ERP, they work with a therapist to develop a plan to do things that will trigger obsessions, so that they can then actively resist engaging in the compulsions that would usually serve to neutralize the troubling thoughts. This is done gradually, beginning with mildly triggering situations and moving up toward ones that would have been intolerable at the beginning of treatment. For example, a person with OCD might have an elaborate ritual for making sure the door is locked (pushing on the door, turning the knob a certain number of times, maybe even taking a picture of the lock) when they leave for work. A mild form of exposure may be to remove one step from the ritual and then resist the predictable urge to turn around on the way to work and check again. Ideally, this would be distressing but bearable, and over time, the client would get used to it. They would then remove another step from the ritual, again resisting the compulsion to go back and check, until such a point as they could simply check the lock once before leaving for the day.
Moving Forward, Not Away
While exposure therapy is highly effective, it can be hard for some individuals to tolerate. For some people with OCD, it makes more sense to focus more on maximizing the non-OCD aspect of their life than minimizing symptoms. OCD causes suffering primarily in that it makes it harder to engage with other necessary or rewarding activities. Treatments like Acceptance-and-Commitment Therapy (ACT) work by helping clients identify the things that are important to them and commit to engaging with said valued activities despite the presence of intrusive thoughts. Obviously, this is easier said than done, but ACT practitioners teach their clients techniques to help make obsessions more tolerable (see our video on cognitive defusion). ACT differs from ERP in its focus on accepting obsessions. However, the two treatment approaches can be, and often are, integrated. ACT can be particularly useful for people with primarily obsessional OCD (a form of OCD with minimal or no compulsions), as well as people who have had significant difficulty with ERP.
Calling It What It Is
One of the ways obsessive-compulsive patterns persist is by convincing the person experiencing them that they are, in fact, not obsessions/compulsions. In other words, part of obsessive thinking is making the case that it’s not actually obsessive. For instance, someone who is afraid that they left the iron plugged in (potentially causing a house fire) will unwittingly start building an argument to justify their concern. They may try to reassure themselves (i.e., “I know it’s unplugged! I always check!”), but OCD always come up with a killer counterargument (“i.e., “Yeah, but the noise outside was distracting me this time” or “Yes! I always check, and as a result, I was simply going through the motions this time and accepted that it was unplugged out of habit!”). Of course, one could argue back with this thought, but OCD doesn’t have any other job but to convince you of its argument (you can think of it as lawyer), whereas people with OCD have more important things they could be engaging with. One way that therapy can help people with OCD is helping them develop greater awareness of when OCD is doing its thing. By becoming better at recognizing their obsessive-compulsive thought/behavior patterns, people with OCD create more opportunities to slow down and choose not to engage with fruitless thoughts, rather than entering into a debate about their validity.
More Than Just Your Symptoms
While some people only wish to work on their OCD symptoms in treatment, others become frustrated, because they feel their clinicians disregard other relevant events in their lives. After all, people with OCD are more than their obsessions and compulsions. If this is a concern, it is a good idea to share it with your mental health provider. They may be able to adjust your treatment, so as to address other important areas of your life, or you may come to the conclusion that their approach just isn’t a good fit for you. Obsessions and compulsions can limit your sense of agency in day-to-day life. One place to take back the power to choose is in deciding how you’ll address it.
Thomas Shooman is a mental health counselor practicing at Resolution Psychotherapy in Poughkeepsie, New York. Thomas’ clients include individuals dealing with anxiety, grief, and obsessive thinking. He enjoys helping people navigate uncomfortable circumstances and find solutions that are in line with their personal style. Thomas is a member of the Association for Contextual Behavioral Science and the International OCD Foundation. To inquire about therapy with Thomas, send him an email at firstname.lastname@example.org.