Obsessive-compulsive disorder (OCD) is generally represented in the public imagination by excessive hand washing, rigid tidiness, and repetitive rituals. This makes sense. We understand the world largely through observation, and these are some of the most observable symptoms (compulsions) associated with OCD. That said, OCD is more than meets the eye. In fact, a lot of OCD phenomena occurs within the realm of thought and feeling, where our observing faculties can’t reach.
Distrust of Reality
OCD is sometimes called the doubting disease, because the disorder seems to be characterized by a tendency to doubt one’s own perceptions. For example, a man with OCD, John, may clearly see that his stove is off but find himself spending several minutes staring at it, making sure that the knob is in an off-position, until he is sufficiently certain that the range is not on. His eyes are registering that the stove is off, but he is unable to mentally move the stove into the “off” category. Put simply, for people with OCD, seeing is not believing. This may be because people with OCD have trouble trusting the distinction between thought and reality. In the previous example, John sees the knob in the off-position with his eyes, and that visual information is processed into a mental representation in his brain. However, like everyone else, John is capable of creating images in his mind that aren’t based on visual input. So, John may also have the mental image of the knob being in the on-position, and whereas most people would feel confident that the off-position image had its origin in the visual field and the on-position image had its in the mind’s eye, John has his doubts.
A Premium on Thought
For people with OCD, thoughts have weight. Whereas most people may judge whether or not they’re a “good person” based on their actions, people with OCD have trouble believing they’re a good person if they have “bad thoughts.” Everybody has aggressive, transgressive, or otherwise taboo thoughts, but people with OCD worry that these thoughts may be a reflection of their character. Furthermore, it can also be hard for people with OCD to confidently accept that their thoughts don’t have the ability to alter external circumstances. They may worry that thinking about a disaster will cause it to happen. In a sense they know this isn’t true, but they can’t help but feel that it is.
This is part of what makes understanding the OCD experience from the outside so difficult. OCD doesn’t cause perceptual disturbances. People with OCD experience reality just like everyone else; the boundary between thought and the outside world is firm. Nonetheless, it’s hard to trust that boundary. If that boundary was a person, someone with OCD might describe them as “shady” or “sketchy.” People with OCD just feel like they need more assurance that their thoughts are confined to their minds.
The Cost of Being Wrong
So, if people with OCD know the difference between thought and reality, why can’t they just ignore the nagging feeling that they might have mixed up the two? Well, the stakes are incredibly high, or at least it seems that way. For instance, John could just tell himself “I’m fairly certain that I saw the stove was off,” but if he’s wrong, there could be a fire that costs him his home, his life, and the lives of anyone who might live with him. In the moment, that really incentivizes him to listen to that nagging feeling and double check. Trouble is, double check becomes triple check, becomes quadruple check, and so on. John knows that this is a bad pattern he’s stuck in, but he can’t bring himself to break it tonight—the potential cost just seems too high.
The Need for Understanding
Because people with OCD have a good grip on reality, they are acutely aware of how strange and frustrating their behavior can be to others. This leaves their loved ones who wish to be supportive in the difficult position of navigating the line between patience and enabling. Ultimately, compulsive behavior can be extinguished and obsessive thoughts can be managed, so it’s not helpful to facilitate someone’s OCD. However, needlessly rushing someone along or mocking their actions is cruel and will only make matters worse. What’s more appropriate is to allow someone to challenge their OCD at their own pace while maintaining one’s own boundaries—and resisting the urge to construct one’s own world around the obsessions and compulsions of another. That’s easier said than done, but what should undergird any effort to support someone with OCD is empathy, an understanding of the sufferer's frustration, and a respectful encouragement to face the challenges inherent in resisting OCD.
Thomas Shooman is a mental health counselor practicing at Resolution Psychotherapy who provides teletherapy to clients across New York State. 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. To inquire about therapy with Thomas, send him an email at firstname.lastname@example.org.