Over the years I have noticed an obscure form that OCD compulsions can take, that many clients and therapists may not recognize as ritualizing. The clients show up at my office highly educated about their disorder. They have read every OCD book on my book shelf and then some. They walk in with a bag of self-help books they are currently reading.
These clients may have visited multiple professionals from psychoanalysts, psychiatrists and cognitive-behavioral specialists, to healers, hypnotists and clergy, looking for answers. They have a large notebook full of writing they had scribbled down while reading or listening to the bevy of helpers, willing to provide the therapeutic information in hundreds of different ways. They are compulsively looking for a solution to their OCD.
The ritual continues when they sit down on my couch. They have razor sharp attention to the words that I say, that they skillfully balance with planning and asking a series of questions in rapid fire. They must be sure they cover everything before the session is over. Being in session is a major anxiety trigger because they feel that it their only chance this week to get the answers they need to reduce their suffering. I call it the “solving compulsion.”
Many of these clients have been through successful Cognitive-Behavioral Therapy (CBT) in the past and feel like they aren’t doing it right anymore. They may have been high achievers the first time they tried exposure therapy. They ask themselves, “Why isn’t it working now?” It is not working now because you’re targeting the wrong fear. Your OCD has pulled the rug out from under you and you don’t even realize it has shifted. The new fear is that you have doubt about your ability to keep your OCD under control. You used to have confidence that you had a handle on your treatment through all your CBT skills, but now your mind is flooded with doubts. Your OCD threatens you with the many consequences that could occur if the bad thing happens. This is your OCD now.
Intrusive Thoughts / Obsessions that proceed compulsive solving:
- Your OCD and panic symptoms will continue to increase until you spin out of control.
- Your life as you know it is taken away because you become more and more consumed by your OCD.
- You don’t understand treatment explanations perfectly enough.
- You don’t explain your experience perfectly enough to get the correct instructions back from your therapist.
- You’ll lose your job because you cannot function normally.
- You’ll lose your relationship because they don’t deserve such an impaired person.
- People feel sorry for and pity you because you have lost complete control of your mental health.
These intrusive thoughts are the new weapons that your OCD is using to encourage you to feed it with rituals. You become desperate to prevent all of these bad events from taking place. You ask yourself, “What is the way to prevent the destruction of my life by my OCD?” “Maybe if I become an expert on my OCD then I can gain control and prevent the feared outcome.” You begin reading and learning, talking to people, and checking in with yourself multiple times daily to see if you are any better. You’re not better, “Oh no!” This could only mean that you have not covered enough ground. Maybe your therapist is not skilled enough and you should see someone else. Maybe your medications could be altered. You search and read online about your medication for hours. You switch psychiatrists because clearly this medication is not working anymore.
You begin to imagine all the terrible things that may be happening to you. “Will I lose all control and my OCD completely take over?” “Will I have to check myself into a mental hospital?” “Will I ever feel normal again?” “Well, I certainly cannot stop my solution-seeking now.” You are in desperate need of more information. During your voracious reading you find a new idea about OCD that you haven’t seen before and a wave of relief rushes over you. “Now I must hold onto this information. I can use it to get better.” You write it in your notebook and a post-it on your mirror. “If I read it every day I won’t forget.” But the relief stops coming. “There must be more gems like that online.” “There is more I haven’t read or seen before.” “If I found that relief I can find more.” The search continues. During the investigation, you find other things that spike your OCD. You are compelled to pore over your notes from therapy. You may begin to compulsively do the assignments that were given by your behavioral therapist with the wrong motive, to feel less anxious. Exposures are meant to create anxiety intentionally until the exposure is unsuccessful at creating anxiety through the process of habituation.
What is the answer then? (I knew you would ask…)
People find it very illogical when I tell them to stop searching for the solution. They do not understand that the solution-seeking is the problem. I understand that it is completely counterintuitive. Stopping solution-seeking will feel like the wrong thing to do. The idea that you are suffering so badly and your therapist is asking you to do less reading, working and planning about how to fix it seems backwards. “How will I stop this from happening if I haven’t found the solution yet?” All of these reactions to your OCD fears make sense. Biologically we are programmed to find a way to avoid painful stimuli.
It is ironic that even coming to me for therapy or reading this article can be part of your compulsive process. Noticing the solving compulsion in a therapy session is critical. It is important for your therapist to understand that they may be participating in your rituals by answering questions repeatedly about how to do the therapy correctly. It is the proper response to allow you to feel anxious and uncertain about whether you explained or heard something well enough. Your exposure is to walk around with doubt about whether your perceived shoddy understanding of your therapy session is going to affect your progress negatively. This is the response that will weaken your OCD. If you do solving rituals in an attempt to be certain that your OCD will improve, you will feed your OCD and it will remain powerful and active.
For example, you may fear that you did not understand the concept of mindfulness well enough after we discussed it in session. Eastern philosophy is often a key target for OCD solving rituals because it can be ambiguous and idiosyncratic in its application. You assume there is a correct way to apply the skills and feel you must find out how to use them properly. It feels too risky to take it for granted that a seed was planted and allow your acquired knowledge to unfold organically. You must know “for sure.”
Discontinuing solution-seeking will feel like flying into the dark with no safety net. That’s how it is supposed to feel when you are doing an exposure correctly. When a man with OCD touches a doorknob without washing his hands, he feels anxious and uncertain. Maybe he will touch HIV-infected blood or someone else’s urine. Feeling the pain of this doubt is how you will know you are on the right track. In your case, sitting with uncertainty and fear about how not perfectly understanding the therapy will lead you to a life of panic and incapacitation, (or whatever your feared consequence might be), without doing more solving is your Exposure and Response Prevention (ERP).
Exposure and Response Prevention
Exposure and Response Prevention is an evidence-based behavioral therapy that has been found to be the most effective treatment for OCD. By learning to face your fears directly (i.e. touching a door knob) and refraining from performing neutralizing rituals (i.e. washing your hands), you eventually habituate to your fears and weaken your OCD. Imaginal exposure is a method where you are asked to imagine or write scripts about your fears. Exposure scripting is a good method to use if you are afraid of losing and not being able to regain control from your OCD. You will attempt to spike your anxiety intentionally by writing about all the ways in which your fear will likely come to fruition, and when it does, all of the horrible consequences you will have to contend with. After you’ve spiked your anxiety, you must resist the compulsion to find the solution to your OCD.
Solving Rituals in OCD
In ERP, we will create a hierarchy of compulsions listing all of the compulsive solving that you are engaging in. This is done so that you can identify when you are slipping into compulsive solving. It might look something like this:
- Create list of questions to ask therapist when I get fear about my therapy
- Asking therapist to repeat instructions
- Online research about OCD treatment or medications
- Excessive note-taking in session
- Re-reading OCD articles or notes taken in therapy office
- Highlighting key concepts in OCD books / reviewing highlighted materials
- Visiting multiple types of professionals / types of therapy
- Researching medications
- Reassurance-seeking / Discussing OCD with loved ones
- Mentally reviewing any reassuring information gathered
- Overdoing homework assignments
- Resisting letting go of assignments after therapist has suggested they should stop
In therapy, your anxiety will spike when you doubt your understanding of the material, which should be viewed as another type of exposure. We will practice sitting with the discomfort and uncertainty of your OCD prognosis. My clients who engage in the solving compulsion often try to guide the session towards psychoeducation. I identify this behavior as a solving ritual, and encourage efforts to experience the desire for answers mindfully. They often leave the office feeling anxious and incomplete. Discomfort is what you should expect after an exposure. But when you begin to understand the solving ritual, you will know that walking away from session with uncertainty is because you had a good session of exposure work.
Experiencing the thoughts and emotions caused by your OCD theme using mindfulness is a necessary step. Mindfulness is the non-judgmental awareness of the present moment and all that it offers. Allow the pain and uncertainty of your OCD to be present in this moment by noticing and inviting it in. You can make room for it if you are mindful. This will help you to resist engaging in the solving ritual. You might ask yourself, “Am I scrambling for a solution right now?” Cognitive-Behavioral Therapists often ask you to rate your anxiety on a Subjective Units of Distress Scale (SUDS). Instead, rate your level of resistance to the discomfort that is present in the moment from 1 – 10. If it is a high number, make a decision to lower your efforts to change the moment. If you don’t fight your OCD, it will eventually learn to stop trying to provoke you.
Having unwanted thoughts and feelings about losing control of your OCD is not the problem. Your effort to rid yourself of your thoughts and feelings is the problem. Realize that the structure of your OCD is now made up of both your overt and mental rituals. These rituals are used to “solve” the fear and uncertainty that you will not be able to gain control back from your OCD. It will feel like a risk to discontinue solution-seeking. I know it seems to be the only glue that is keeping your OCD at bay. In the beginning, learning about your OCD was helpful. It is important to recognize when to shift gears and acknowledge that the same behaviors are having a very different effect. Facing uncertainty and anxiety offensively is the method of treating all forms of OCD, and this is no different. Move forward bravely and take the chance that your OCD will spin out of control. You will deplete your OCD of the oxygen it needs to survive, your solving rituals.