Mental Compulsions and OCD
A primary feature of all OCD is participation in compulsions. Many compulsions are observable behaviors, such as: Washing your hands, keeping all the knives in the house locked in the garage, driving round and round again, checking to make sure the stove is off, asking for reassurance.
Mental compulsions are often overlooked and sometimes harder to reduce.
This post will explore the function of mental compulsions by reviewing several examples and then describe skills involved in reducing them.
The Function of Mental Compulsions (with examples):
Within OCD, compulsions are the behaviors we complete in order to neutralize / suppress intrusive thoughts and reduce our anxiety. This is true whether our compulsions are observable behaviors (like checking to make sure the front door is locked) or unobservable mental behaviors (such as repeating a particular phrase in your mind over and over).
To illustrate how mental compulsions function, let’s review several examples:
Example 1: David’s Mental Compulsions
David’s primary OCD theme area had to do with numbers. David was particularly concerned with the number “666”. When David saw this number, he would almost always have the thoughts “Oh my goodness, my seeing this number might mean that something absolutely terrible is about to happen to someone I love (e.g., they might die in an accident). In order to protect this person from dying, I need to remove the number from my consciousness.”
In order to remove the number from his consciousness, David repeated, in his mind, a specific prayer seven times. When saying this prayer seven times, he had to be sure that no unacceptable thoughts arose. If an unacceptable thought came up, David had to start his seven-prayer process from the beginning. Sometimes David was able to complete his prayers in just a handful of minutes. Sometimes, though, it would take David up to an hour to complete the process “just right” with no unacceptable thoughts. As you can imagine, David didn’t enjoy the anxiety-filled and energy intensive process of completing his prayers, especially because he never knew if his prayers would be done in ten minutes, an hour, or even more.
As his OCD progressed, David noticed that he was becoming triggered in more and more situations. Initially, David would only become anxious if he saw the full number “666” (e.g. seeing 666 steps while walking on the treadmill). However, as time went on, he noticed that even seeing the number “6” would trigger him. That is, any time he saw a “6”, his mind would flash “666” and then he’d have to complete his compulsion. As a result, David began doing everything he could to avoid seeing numbers. He kept a towel over the display panel on the treadmill. He put sticky notes over the odometer on his car. He didn’t look at menus at restaurants anymore due to the presence of numbers. He did everything he could to avoid being around clocks.
Unfortunately, despite his best attempts, his OCD continued to evolve. For example, if he saw six birds on the sidewalk, he would become triggered. If, on the way into the grocery store, he saw three grocery carts not properly put away within the grocery cart return area, he had to be very careful not to see these three carts on his way out (because three plus three is six which would activate the thought 666). And so on.
As a result, David began to participate in other mental compulsions besides praying in response to being triggered. For example, David began to repeat a protective prayer immediately upon leaving his house. Although his proactive, protective prayer helped him feel better at first, he quickly noticed that any time he wasn’t saying his protective prayer he would become anxious. Thus, David began saying his protective prayer more and more. And, so, more and more of David’s life was absorbed in his intrusive thoughts, anxious feelings, and mental compulsions.
Example 2: Tracy’s Compulsions
Tracy’s primary OCD theme area was related to a fear of being sexually attracted to children. When Tracy saw a child, she would almost always have the intrusive thought “Am I attracted to that child?” In order to “figure out” if she was attracted to a child, Tracy would pay very close attention to how her body was feeling any time she saw a child. “Is my heart beating a little faster? Am I getting hot? Did I just notice a tingling in my genitals?”
Unfortunately, the more Tracy paid attention to her body, the more engrossed and concerned she became in her bodily sensations. She noticed a wide variety of bodily sensations, from “zips” and “zaps” in her arms and legs, to flushed cheeks, to the amount of vaginal lubrication she believed she was experiencing.
Because Tracy almost always interpreted these bodily sensations as signs of sexual arousal (which connected to her fear of being a pedophile), she participated in a comprehensive set of mental processes designed to reassure her that her bodily sensations were not, in fact, indication that she was sexually aroused. For example, if, upon seeing a child, Tracy felt a “tingle” in her genital area, she would focus on the tingle while repeating in her mind the phrase “I’m a good person and I’m not attracted to children.” She found that, if she did this long enough, the tingle would go away and this, she interpreted, was a sign that the tingle was not a true indicator she was sexually aroused.
Unfortunately, much like David, Tracy never knew how long her mental compulsions would take. Sometimes she “felt right” after five or ten minutes of mental compulsions. Other times, she would spend half the day trying to neutralize a particularly troublesome intrusive thought and related bodily sensation.
As you can imagine, Tracy began spending more and more time doing everything she could to avoid seeing children. Initially, this meant avoiding the playgrounds in her neighborhood. However, over time, Tracy began reducing the TV and films she watched (they might have children), books she might read (children characters or characters talking about children), and conversations with friends and family (what if they mention their kids?).
And, so, more and more of Tracy’s life was absorbed in her intrusive thoughts, anxious feelings, and mental compulsions.
Example 3: William’s Mental Compulsions
This is a description of my own struggle with mental compulsions.
My primary OCD theme area was that I would be bit by a rabid bat and not realize it. My intrusive thought story told me that if I didn’t realize I was bit by a rabid bat, I wouldn’t get the rabies vaccine. And if I don’t get the vaccine, but I was bit by a rabid bat, by the time symptoms of rabies begin to show, it will be too late to get medical care and I will die a gruesome death.
As a result of this intrusive thought, it became very hard for me to be outside (later during my OCD, it was very hard for me to be inside as well). If I saw an object on the ground, such as a leaf, a piece of paper, or even a can of soda, I would almost always immediately have the intrusive thought “What if that object is actually a rabid bad that bit me without me knowing it?”
If at all possible, I would stop to examine the object carefully, often taking pictures of it with my phone and frequently picking the object up and saving it so I could check it later if I worried it might be a bat.
Many times, though, I wasn’t able to check an object (e.g., I often would be too embarrassed to complete a careful check or take a picture if I was with other people). In these cases, I would take as close of a look as I could while walking by and then, afterward, go over and over in my mind what I remembered seeing.
In these cases, a typical process in my mind would look something like me repeating the phrase: “I just walked past a piece of trash on the ground. This piece of trash was green and purple and looked just like a wrapper from some kind of candy. This piece of trash did not look at all like a bat. I was always at least two or three feet from this piece of trash at all times. I never got within two or three feet of this piece of trash. I did not feel any scratch, bite, or any other kind of damaging contact on my feet, ankles, legs or anywhere else on my body. I am safe and I was not bit by a bat.”
I would visualize what had occurred while saying the phrase over and over. Sometimes I would feel better within five or ten minutes. Other times, I was completing my mental compulsions for hours.
What’s more, I began to have other intrusive doubts such as “How do I know that my perception and memory are working correctly?” As a result, I began to add more content to my mental compulsions, including the phrase “I’m aware, coherent, rational, and clear-headed. I’ve not had any drug. I’m not impaired in any way. My memory, perception, and judgement are working within normal limits.”
Unfortunately, I began to have concerns that perhaps, some way somehow, my mental faculties weren’t working correctly or spontaneously “blanked out” at particular times, leaving me with memory gaps and, my intrusive thoughts told, me vulnerable to rabies. Thus, I began to complete my compulsions more and more in order to demonstrate that I was “aware, coherent, rational, and clear-headed” and would go over my memory again and again at the end of the day to do my best to make sure that there weren’t any gaps that could be “cause for concern”.
And, so, more and more of my life was absorbed in my intrusive thoughts, anxious feelings, and mental compulsions.
The Function of Mental Compulsions and What To Do Instead:
In all of the examples above, although the content of the intrusive thoughts and related mental compulsions were different, the function of the process was the same. David, Tracy, and I all experienced intrusive thoughts that told us a scary story that might happen. This scary story made us anxious. Our anxiety motivated us to do something to keep ourselves safe and get rid of the intrusive thought and anxious feeling. Sometimes we would do physical behaviors. But other times, our behaviors were completed within our own minds.
The purpose of the mental compulsions was to reassure ourselves that the scary story being told to us wouldn’t happen and thereby neutralize the intrusive thought and related painful, anxious feelings. Often enough, the mental compulsions would do their job (even if the compulsions sometimes took hours) and we’d feel better. Sadly, it wouldn’t be too long before the next intrusive thought arose and we’d have to start the process over again.
Of course, this pattern is the essence of OCD.
The process of challenging OCD includes the process of confronting our feared objects, situations, and thoughts and abstaining from our compulsions. If someone’s primary OCD theme area includes the intrusive thought “I might become contaminated with a deadly germ” and the compulsive behaviors are to avoid touching things and wash excessively, OCD treatment includes the process of confronting those “contaminated” objects (e.g., a door handle), touching them, and letting the thoughts “My hands might be contaminated. I might die from a deadly germ” be present while not washing their hands or participating in other safety behaviors (read more about the importance of acceptance and uncertainty here and here).
To illustrate abstaining when it comes to mental compulsions, imagine Julie who commonly had the intrusive thought “What if I lose my job?” A mental compulsion related to this thought would be participating in a mental process to “know for sure” or “figure out” if she was going to lose her job. For instance, some of the thoughts Julie might consider are, “I probably won’t lose my job, because my last evaluation from my supervisor was very good.” Unfortunately, this thought then runs into Julie’s next doubt, “But what if my supervisor’s assessment of me has changed and now my supervisor is displeased?” Which, in turn, leads to further mental compulsions, including, “OK, I don’t think I’ve seen any signs from my supervisor that she’s displeased with me, but was I paying close enough attention to my supervisor during our last meeting?” Followed by a detailed memory review of every last detail she can remember about her interactions with her supervisor. We call this process participating with the thought and this participation is a mental compulsion.
If Julie were to abstain from participating with the doubts, then, for example, when Julie had the thought “What if I lose my job?” or “How do I know I’m not going to lose my job?”, she could respond by telling herself “Oh. There’s that thought about losing my job again. I sure wouldn’t like to lose my job. And I don’t think I’m at risk. But maybe I will lose my job and then I’ll have to deal with the consequences. However, I’m not going to participate in this thought because I want to overcome my OCD and not completing mental compulsions is the road to overcoming OCD. So, that thought ‘What if I lose my job?’ can be there as long as it wants but I’m not going to participate with it.”
Let’s see how this same process would apply to David. Over the course of David’s treatment, his task was to confront more and more challenging situations in which his scary intrusive thoughts arose and then allow those scary intrusive thoughts to be there without neutralizing them with his special prayer (or other safety behaviors). Thus, when he had the thought “Oh no, I just had the thought 666 and now my wife might die if I don’t say my prayer” he practiced accepting the presence of his intrusive thought (e.g., 666; What if my wife dies if I don’t say my prayer?) and not saying his prayer. He practiced allowing the thought (and the anxiety related to the thought) to be present without participating in a mental compulsion.
So, when David had his intrusive thoughts, he could say to himself, “Oh. There’s that 666 thought again. I sure wouldn’t like something terrible to happen to my wife. And I don’t think my thoughts have any connection to my wife’s well-being. But maybe if I don’t do my prayer, something bad will happen to my wife and then I’ll have to deal with the consequences. However, I’m not going to participate in this thought because I want to overcome my OCD and not completing mental compulsions is the road to overcoming OCD. So, that thought ‘What if this number causes something terrible to happen to my wife?’ can be there as long as it wants but I’m not going to participate with it.”
As you might guess, David had been saying his prayer for years. And so, often, he noticed his safety prayer automatically activating upon becoming aware of an intrusive thought. In these cases, David’s OCD healing process included practicing noticing the prayer automatically activating but, again, not participating in it.
In these cases, David would become aware that his prayer was automatically activating and also become aware of his intention to not take part in the prayer. Thus, if after having an intrusive thought, he noticed the phrases of the prayer going through his mind, he reminded himself “Oh, there’s my safety prayer. Of course I’m going to notice my safety prayer. I’ve been saying that prayer for years and it’s in the “muscle memory” of my brain. My intrusive thoughts and my automatic prayer thoughts can be there as long as they need to but I’m not going to actively participate in the prayer.”
Similarly for Tracy.
Her OCD healing process included noticing the intrusive thought “I might be attracted to children” and, instead of microscopically examining all of the sensations of her body, doing her best to let the intrusive thought and related feelings to be there without participating with them.
Of course, when she started this process, she still noticed all sorts of bodily sensations after having an intrusive thought. And when she noticed these bodily sensations, she had more intrusive thoughts (e.g., “Does this tingly feeling mean I’m sexually attracted to a child?”). But, instead of trying to “figure out” or “know for sure” if her bodily sensations were signs of sexual arousal, instead, she practiced her cognitive reframe “This bodily sensation probably doesn’t mean I’m attracted to children. It’s probably just my OCD. But maybe it’s not my OCD and I am attracted to children. Either way, I’m not going to actively participate in trying to figure out what my bodily sensation means because I want to overcome my OCD and abstaining from mental compulsions is the price of healing.”
Likewise for me. When I had my intrusive thoughts that maybe that item I just walked by was a rabid bat that bit me without knowing, my OCD healing process included reminding myself that I would almost certainly not die of rabies…but maybe I would. Either way, I’m not going to go through a memory review of that situation because I want to overcome my OCD and abstaining from compulsions, physical and mental, is the price of achieving remission from OCD. And, so, if the thought “That might have been a rabid bat. I might die of rabies” stuck around for minutes, hours, or days, I resolved to let it be there without trying to make it go away and without trying to “know for sure” or “figure out” that I’m not going to die of rabies.
Of course, not participating in compulsions, physical or mental, is much, much easier said than done. It’s very scary for a number of different reasons (read more on the object level and metacognitive reasons here). The whole purpose of OCD treatment is so that someone struggling with OCD can get support in a process of acquiring new skills, becoming stronger, and going through new learning experiences that result in them having far less intrusive thoughts, far less anxiety, and living their life much more freely.