Commitment in OCD Treatment
Overcoming OCD almost always requires commitment. Most of us with OCD won’t follow through with enough exposure and response prevention exercises because we feel like it. It’s rare to want to complete an exposure.
We participate in ERP, not because it feels good, but because we’ve decided to take the calculated risk of participating in ERP. Why we’ve decided to take that calculated risk can vary between people.
Most of the OCD sufferers I’ve worked with are choosing to take that risk because, in large part, they want to overcome OCD. But why they want to overcome OCD, although sharing similarities between people, is individually specific.
Greg’s Example:
Consider Greg, whose OCD showed up in many different ways but was typically related to the fear that he’d experience an unlikely catastrophe. Greg had been experiencing ambivalence around completing ERP for quite some time. On the one hand, he believed he had OCD, he believed that ERP was an effective treatment for OCD, and he very much wanted to get out of the pattern of constant intrusive thoughts, anxious feelings, and compulsive behaviors.
On the other hand, he also knew that if he stopped doing his safety behaviors, maybe something terrible would happen. And maybe, even if he went all in on his ERP treatment, ERP treatment wouldn’t work for him. And, of course, just the idea of not completing his rituals made Greg feel terrified.
A turning point came when Greg’s twin boys, both six-years-old, made a request of Greg for their birthday: That Greg come swimming in the ocean with them.
Greg had been terrified of swimming in the ocean since his mid-twenties. Although he’d grown up in California, and had enjoyed swimming in the ocean for decades when he was younger, after his OCD onset, one of his obsessions was being attacked by a shark.
If Greg even considered swimming in the ocean, he’d have vivid images of himself treading water with a hungry great white shark headed his way. He could see the shark’s eyes and teeth as it bit into Greg’s leg. Blood everywhere as the shark dragged Greg underneath the water and finished the job. Understandably, these thoughts alone – much less actually getting into the ocean – caused Greg tremendous anxiety.
Unsurprisingly, Greg had done significant research on his chances of being attacked by a shark if he was swimming in the Pacific ocean on the California coast. His chances of being attacked by a shark were one-in-the-tens-of-millions. Greg knew his chances were very low – much lower than his chances of dying in a car accident (and Greg didn’t get anxious at all about driving in his car). Further, Greg didn’t get anxious when his boys, his wife, or his friends went swimming in the Pacific, even though Greg knew their chances of being attacked by a shark were the same as his. But none of this information changed how Greg felt when Greg thought about swimming in the Pacific.
But now Greg was confronted with his sons’ birthday wish: All they’d asked of Greg was that he swim in the ocean with them. And Greg wanted to, and believed he should, deliver on his sons’ request.
Greg and I reviewed all the information he needed to know about OCD and ERP in order to successfully complete ERP, including:
And we spent considerable time identifying Greg’s values and how these values were related to his commitment to take calculated risks.
Greg made the commitment that he was going to overcome his fear. And so we worked together in creating his graded hierarchy and systematically climbing it.
We finally got to the point on Greg’s hierarchy which included him getting in the water. By this time, Greg had become very good at the two central skills developed in ERP, distress tolerance and psychological flexibility. But Greg being very good at these skills didn’t mean that Greg didn’t feel afraid. It meant that when Greg felt afraid, he allowed those scary feelings to be present. And he allowed the thoughts related to those feelings, including the scary images of being attacked by a great white shark, to stay in his mind. And he didn’t scan the water. He didn’t stay next to the shore.
He swam without safety behaviors. And, exactly as the scientific research on ERP predicted, Greg overcame his fear of being attacked by a shark.
Matt’s Example and Matt’s Insight:
I was reviewing this example with another one of my clients, Matt, who was also experiencing ambivalence about completing ERP treatment.
Matt was a very bright young man who’d been experiencing OCD for the past year. Like many, his fears were numerous. But his most common obsession was the fear of having a fatal heart-related condition that would kill him. As you probably can guess, Matt spent a lot of time checking in on his heart, measuring his pulse, trying to “feel” that his heart was “OK”, and avoiding activities which might elevate his heart rate (exercise, drinking caffeine, anything that might be exciting). He had a very close relationship with “Dr. Google” and had spent tens of thousands of dollars on appointments with heart doctors (who all gave him the same clean bill of health).
But despite all of this, Matt got stuck on the same sort of thoughts again and again: “What if the doctors have all missed something?”; “I really do feel something ‘off” in my heart, and what if this is going to kill me?”; “What if the tests I’ve had done were correct but my heart condition just started and now I really am at risk?”
Matt and I reviewed that, even if Matt spent the next ten years getting the most comprehensive tests completed by the world’s leading heart experts, his OCD would continue to bombard Matt with “What if” questions that, although unlikely were not 100% impossible.
“So”, I asked Matt, “How come you might be willing to take the risk of not completing your safety behaviors, like going in for another heart exam?”
Matt, like many of my clients, was struggling to find an answer to this question. And so Matt and I reviewed Greg’s example and I’ll never forget Matt’s response during this review.
“Matt, if Greg actually had been attacked by a great white shark during his ERP treatment, does this mean that you think Greg was dumb and made a bad decision to get into the ocean?”
Matt looked at me, and without skipping a bit, said, “If Greg had been attacked by a shark during his exposure, then we have to build him a statue!”
“But”, I responded, “Why would we be building a statue to Greg for…making a mistake?”
Matt knowingly smiled as he looked at me, “You know, William. We’ve talked about this and now it’s clicking. Sure, from an omniscient point of view, Greg’s decision was a mistake. But Greg doesn’t get omniscience. None of us do. All Greg can do is try to make the best decisions with the information available to him. Greg knew that OCD was devastating his life and that ERP was the way to overcome it. So he was brave and he took the calculated risk. It would have been a tragedy if a shark actually did attack him. But Greg knew the risks of being attacked by a shark were far, far less than the risk OCD was posing to his life. He did the right thing. I don’t want to build him a statue because he “made a mistake”. I want to build him a statue because he faced his fear. And that’s what’s important. That’s what we’re honoring.”
Matt and I then applied this same line of thinking to his fears and agreed that the same “build that man a statue” reaction would be justified if Matt very bravely decided to abstain from his safety behaviors and, in an extremely unlikely (but possible) tragedy, Matt died from a heart attack.
The above is what I mean when I review that overcoming OCD requires commitment. Overcoming OCD means honestly confronting our fears without a guarantee of the outcome that we want. And one of the ways of staying committed to that decision is to recognize that even if the unlikely (but possible) catastrophic outcome occurs, we still honor, and would still be proud, of the decision to tell our OCD something like, “The shark might get me. But you won’t. At the very end, I went down resisting you. And that means that even though I died, I died victoriously.”