Metacognition in OCD (Round 2):
One of the things that scares those of us with OCD is the possibility of a bad event occurring (e.g., hitting someone with our car without realizing it; becoming infected with a disease; having done something terrible in the past and not remembering it; doing something terrible to someone; missing out on an important life experience, etc.).
But, for many with OCD, there are other things we’re afraid of (even if we don’t realize it): Our own uncontrollable thoughts and feelings. In my practice, we call concerns about our own uncontrollable thoughts and feelings “metacognitive” concerns and I see them all the time with my clients.
In my blog, I’ve previously reviewed metacognitive concerns. But, I want to come at the subject from another angle in case this other angle causes the idea to “click”.
Some months ago, I was reviewing treatment history and conceptualization with a client (we’ll call this client Andrew) as he was winding down treatment (as a result of being in remission; wahoo!).
During this review, we were reflecting on the “mistakes” Andrew made when his OCD began. I wrote mistakes in quotes because it wasn’t really a mistake – Andrew had no idea what OCD was or how to respond to OCD-related experiences. But, from an omniscient point of view, when he first experienced intrusive thoughts, he responded to them in a way that not only wasn’t helpful, it made things worse. Much worse. Let me tell you the story.
When Andrew’s OCD first began, he was on the brink of graduating high school. He was looking forward to college. And looking forward to summer. A couple weeks before he was set to graduate, he was wrapping up some final school assignments and thinking about what it would be like to have most of his family visiting. He thought of his grandparents, aunts, uncles, and cousins that would be flying in.
And then it happened. The thought of Andrew’s uncle Calvin. Andrew hadn’t seen Calvin in a long time and he was trying to remember what he looked like. No matter how hard Andrew tried, he couldn’t recall Calvin’s face. Eventually, he asked his mom for a picture.
“Oh yeah” Andrew thought, as he saw Calvin’s face. “Well, that’s that” Andrew thought.
But that wasn’t that.
The image that kept coming back
Just a few moments later, Andrew noticed the image of Calvin’s face come to mind.
“That’s weird” Andrew thought, as he went to play a computer game with some friends. Throughout the time Andrew spent playing the computer game, Calvin’s face kept popping up.
It was distracting. And it wouldn’t go away. No matter what Andrew did, Calvin’s face kept showing up.
Andrew’s time playing a computer game with friends was damaged because he was having a hard time focusing. Eventually, he stopped playing. But Calvin’s face remained. It showed up when Andrew was eating dinner, getting ready for bed, and when he was trying to sleep.
Now Andrew was starting to get scared.
“I can’t control this image” he thought. The more Andrew tried to control the thought, the more he realized he couldn’t control the thought. His heart started beating faster. His head was getting hot. “Am I going crazy?” he wondered.
What followed over the next several days was extremely painful. Andrew became more and more aware of the image of Calvin’s face and he eventually reached panic-level anxiety. This culminated in my client reaching out to his parents. His parents didn’t really understand what Andrew was describing, but they could see that he was extremely anxious. Andrew’s parents didn’t know what to do so they called their doctor. The doctor didn’t understand what the parents were describing either, and recommended that they take Andrew to urgent care. The urgent care doctor also didn’t understand what Andrew was describing but could see that Andrew was very anxious. The doctor ran some tests and told Andrew that Andrew was having a panic attack and that he would be fine.
Andrew felt better. And, for some reason, the image of Calvin went away. Until the next morning. And the cycle continued.
This is a good moment for us to take a step back and review what Andrew told me about what he remembered about Calvin’s face. Calvin’s face wasn’t scary. Andrew had always enjoyed being around Calvin when Andrew was younger. There were no bad memories related to Calvin. There was nothing at all about the image of Calvin that bothered Andrew.
Put differently, it wasn’t the content of the image that bothered Andrew.
What bothered Andrew was that Andrew didn’t have control over the image showing up. And the more Andrew tried to establish control, the less control Andrew had.
This, in turn, resulted in Andrew having thoughts about the image, thoughts like “Why can’t I make this image go away” and “Am I going crazy” and “Am I going to be stuck with this image for the rest of my life?”
Those thoughts “Am I going crazy?” and “Am I going to be stuck with this image for the rest of my life?” are scary thoughts. That doesn’t mean I, as an OCD specialist, believe those thoughts. But the idea of going crazy, the idea of getting stuck with an unwanted image for the rest of his life, are scary ideas. So, Andrew’s increased anxiety was understandable.
When we weave this together, we can now see more clearly why I support my clients understanding that one of the things that can be scary about OCD is a confrontation with split consciousness. By split consciousness, I mean the experience of an unwanted object of awareness (usually described as an “intrusive thought”).
Frequently, perhaps even most of the time, the content of an intrusive thought (e.g., unknowingly hitting someone with your car; inexplicably losing control and stabbing someone, etc.) is very scary. But not always. Sometimes, the content of the intrusive thought is entirely benign. In cases where the content of the intrusive thought is entirely benign but still scary, it’s usually the process that’s scary (e.g., coming into contact with the fact that you’re not entirely in control of your own consciousness).
In fact, there are a variety of well-known OCD theme areas that center on just this type of concern. For instance, if I’m working with someone with a sensorimotor theme area, their concern is that they frequently notice aspects of their experience that they don’t want to notice, such as their breathing, swallowing, blinking, how their feet feel, etc.
In these sorts of OCD presentations, it’s not typically the case that they believe their awareness of, say, their breathing is a sign that they’re about to die. Instead, their concern is usually something like, “I can’t stop focusing on my breathing and it’s damaging my life because my other activities are ruined by my awareness of my breath.”
Again, in these instances, we can see that it’s not the content of the intrusive thought itself that scares them, it’s the fact that they are having an intrusive thought they can’t control and what that might mean for their future (e.g., no longer being able to participate in activities they enjoy because those activities will be “ruined” by the intrusive thoughts).
The scary image that kept coming back
These sorts of concerns apply in a similar way to my clients with scary intrusive thought content. For example, if I’m working with a client who is concerned they might inexplicably push someone into oncoming traffic, one of the things that scares them is the possibility that they might inexplicably push someone, resulting in the death of an innocent bystander and my client going to jail.
But another thing they’re afraid of is having distracting, unwanted thoughts and related painful and anxious feelings every time they leave their house even if they don’t push someone.
How many times have they pushed someone into traffic? Never. But how many times have they become stuck with the unwanted, distracting thoughts and the related painful, anxious feelings? All the time. What was it like to have these thoughts and feelings even though they didn’t push someone? Very distracting and very painful.
Understandably, they stop going outside because they confidently expect the thoughts and feelings to show up if they leave home.
What’s the exposure and response prevention (ERP) solution to this type of concern? It’s the same as the ERP solution to all OCD-related concerns: Accept the unwanted, distracting thought and related painful anxious feelings. We’ll review that everyone has intrusive thoughts and that basically no one is able to control intrusive thoughts via thought suppression. And then we’ll learn about and practice our distress tolerance and psychological flexibility skills.
If we come full circle, what advice would Andrew have given his younger self when the images of Calvin intruded into consciousness?
Andrew smiled when I asked him this. Andrew told me, “I would tell myself that it’s annoying that the image of Calvin is present and that the image can be there as long as it needs to and I can still play my game with my friends. I’d tell myself that the image might be distracting at first, but the more I practice just letting the image of Calvin be there, the easier it will become for me to pay attention to my game even though the image of Calvin is present. And eventually, I’ll get so good at allowing the image to be present that I won’t care about it being there. Then I won’t be bothered by it much at all, even if it does show up. Then I can get back to living and enjoying my life.”
Exactly right.