OCD and Psychotherapy
Dr Jonathan Haverkampf
Obsessive-Compulsive Disorder (OCD) is a condition in which people feel the need to check things repeatedly, perform certain routines repeatedly (‘rituals’), or have certain thoughts repeatedly. People are unable to control either the thoughts or the activities for any longer periods of time. Suppressing the behaviour or thoughts often causes intense feelings of anxiety, tension, nervousness and fear. OCD is quite common, and it is mostly treated with a combination of psychotherapy and medication.
The rituals and thoughts in OCD usually have the objective to prevent accidents or and other negative outcomes that pose a serious threat to the individual’s life and well-being or to goals that are important to the individual. The rituals can be checking whether a door is closed multiple times, walking only on every second tile or washing one’s hands for an extended period of time. Thoughts can include counting or doing things in certain quantities. Intrusive thoughts can also be about harming another person, which seems alien to one’s personality. Some might still have obvious meaning, like someone who moved a lot in childhood checking the door compulsively, while other urges, such as counting all the lighter coloured tiles on the wall, may not seem to make much sense.
All the behaviours and thoughts have in common is that they provide an option to reduce anxiety by focusing on behaviour and thoughts that seem to have a clearly defined system, no matter how illogical. But they often are not very effective. Anxiety can actually increase if one gets caught in these thought and rituals. But why are they still used? I believe they are a feeble attempt to calm oneself when there is no one else available to do so. What causes the anxiety is an intolerable probability of negative emotions in the future. Rather than experiencing the negative emotions in the future I experience them now. If I am afraid of a relationship breakup, I experience now anxiety about the potential future emotions from the breakup. The less certain I feel about the future, the more I do things that seem certain to compensate for the uncertainty and feel more certain. Of course, this a subconscious process, but it is important to see that the brain engages in self-regulation. To get out of this one either needs to see the world as more certain or the uncertainty as less of a burden. Better communication with the world takes care of the first part, a better for oneself of the second.
Like many other psychiatric conditions, OCD begins at the boundary of normal behaviour and thought, the little everyday rituals and the occasional nagging thought, that are hard to suppress but do not interfere with one’s life and happiness. At the other end of the spectrum is the house bound, or even bed ridden individual who can no longer take part in daily life. In the latter case, getting dressed can take hours and such mundane things as washing one’s hands get caught up in endless loops of repetitive or highly ritualized steps. The obsessive element of OCD refers to repetitive thoughts, like counting things, while the compulsive element refers to repetitive behaviour, such as walking upstairs by making sure to only tread on each step with the left foot first. Sometimes OCD only consists of obsessions (thoughts) or only of compulsions (behaviour). In most instances, however, it means both. Suppressing these behaviours or thoughts can cause feeling of uneasiness, anxieties and fears of dramatic events.
The therapy of OCD can be supported by antidepressants, mainly in the form of serotonin reuptake inhibitors or older tricyclics. But nothing has quite the lasting effect of psychotherapy. The reason is that OCD appears to have a biological component, but that the psychological and social aspects play a large role in triggering and maintaining it. There is probably a predisposition for OCD and some individuals are more likely to develop OCD in stressful situations or after negative life events. Others who have a different predisposition may develop some other condition, such as outright anxiety, or self-medicate with alcohol or drugs in the face of psychological pressure. Sometimes there may not be an apparent trigger of the condition, but quite often there is.
Anxiety is acutely felt once the repetitive behaviours or thoughts are suppressed. This anxiety comprises the sense of tension, fear of impending doom and other unpleasant emotions. It increases when existing mental resources are already low due to stressful life experiences, internal conflicts or interpersonal difficulties. Relationship or workplace problems, the pressure of not meeting one’s expectations or a loss of direction in life may all help trigger OCD.
Many techniques can help in confronting OCD, including mindfulness and meditation, but nothing quite helps as much as learning healthier interaction patterns with oneself and others and clarifying one’s values, needs and aspirations. An environment that is predictable yet stimulating has a positive effect on OCD, but it often needs to be created from scratch. The experience of stable relationships helps, while a loss of faith in the predictability of human interactions and helplessness and loneliness can make it worse. Babies learn to feel safe in the world through their interactions with their primary caregivers, children through their interactions in and outside of school, adolescents through social and romantic relationships, and adults in a myriad of business, academic, athletic and romantic relationships. If I have difficulties in communicating my values, needs and aspirations to my environment, the world is more uncertain and I will have more stress, which leads to a greater likelihood of stress, anxieties, panic attacks, OCD, burnout and a host of other psychological and medical conditions in the long run. Important is the act of communication, which can also be ‘virtual’, one reason why keeping a journal or writing down one’s thoughts has been helpful to many people with anxieties and OCD. The act of communication helps to define and live one’s values and aspirations, which give the individual a sense of stability.
Learning to communicate and interact with others is a lifelong learning process, and it also reflects on and determines how we think about ourselves. If one’s communication patterns are not helpful, existential anxieties can ensue, because our sense of self and our social existence is linked to how we experience our relationships with others. Do we address what we want? Do we say ‘No’ to the things we do not want? Even a monk who meditates months on end needs to learn to communicate with himself to find tranquillity and with others to survive. Our health, mental and otherwise, depends on how we shape our interactions with the world, as do any achievements in the arts, sciences and business and in relationships.
To treat OCD means predominantly to treat the anxiety underneath it by focusing on the emotions that cause it, such as remnants of fearful or hurtful life experiences. The key for the therapist is to build a working relationship the client that helps lower these anxieties while facilitating the therapeutic work. This requires paying attention to the interaction patterns clients use and then reflecting on it together with them.
Reflecting on the thoughts and daily life which are associated with OCD symptoms should foster a greater openness to try out new perspectives and reach new insights. Various issues from the presence and the past may come up which need to be interpreted in light of the emotions they evoke. Issues are especially important when they change how the individual communicates with the world. If you have nightmares about spiders, the spiders in themselves may not be relevant in themselves. You could also dream about monsters or your boss with the same emotional reaction. Only if the spiders change how you see yourself or others are they relevant in a dream and have an influence of how you interact with yourself and others. In OCD the repetitive behaviours and thoughts are only relevant because there are thoughts and emotions underneath them, which have not yet fully been communicated.
Breaking down the meaning in the rituals needs to be approached carefully yet thoroughly. The rituals usually give clues of the thoughts, emotions and subjective experiences that help maintain them. Reflecting on why it may be difficult to communicate the underlying dynamics can be central in resolving the OCD symptoms. Rape victims, for example, might feel terrible shame in talking about their feelings and this maintains the rituals as a form of incomplete communication. Breaking down the shame into its components usually makes it disappear along with the OCD symptoms. Usually this does not even require addressing the traumatic event itself, which may just cause fear and resistance. This does not mean integrating a rape as ‘normal’ into one’s experiences, but removing the negative effect it has on one’s life and relationships.
Identifying one’s value, needs and aspiration has another important aspect in dealing with a number of psychiatric conditions. As the individual recognizes them as largely constant through the years, they can induce feelings of safety and security. They have a significant influence on our life, but are highly predictable if one spends the time on identifying them. Insight about them can even be gained when reflecting on the specific manifestations of the OCD symptoms, especially when they are suppressed. After all, these symptoms are maintained by powerful emotions which must be attached to something that is highly relevant to the person. Treating any kind of psychological symptoms is an opportunity for greater insight into oneself.
The fears and anxieties in OCD can lead to ambivalence and resistance towards therapy. An empathic therapist offering sufficient space for reflection and emotional expressiveness helps the client understand that there is nothing to be afraid of. The anxieties underlying OCD are really psychological tensions misinterpreted as fears. They can persist as fears as long as they are not shared and communicated. Psychological tensions can arise from many sources. Maybe at some point in life we really have been fearful, but after the feared situation disappeared, only the tension remained, which then persists and can then lead to the OCD symptoms. Interestingly, once this tension becomes a topic in therapy it may increase at first as it becomes conscious but then tends to vanish as it is seen as only a symptom of an underlying conflict or dynamic that is or relevance to the individual’s values, needs and aspirations.
Psychological tensions may have multiple explanations. They may be related to past experiences involving people important to us, such as primary care-givers, real or imagined love interests and so forth. It does not matter so much whether a relationship was real or imagined because the subconscious of our brain is not so good in making this distinction anyhow. Revisiting past communication patterns, including our reactions in stressful situations and events, helps us identify how we interact with others in the present. It is also helpful to acknowledge one’s success in putting obsessive behaviour or compulsive thoughts to rest.
Obsessive thoughts and compulsive behaviour can be put in categories, which already lowers their incidence. Chunking them in smaller units helps make feelings of anxiety and fear more manageable. The next step is to observe what happens when a ritual is not performed, whether it is washing one’s hands or the compulsive thought to count all even numbers squared up to 88. Suppressing these rituals may cause anxiety or fear that something specific is going to happen. Interestingly, the concrete fears are often easier forgotten than the rituals, because the former are only placeholders for other uncommunicated fears on a deeper level. One reason for maintaining the rituals is to avoid feeling guilty for not carrying out the ritual and causing a catastrophic event, but in this case it is the guilt and or any other underlying issues that need to be dealt with. Then the rituals often stop.
Rituals only have meaning to the affected individual, which is one fundamental thing to understand about OCD. Only if we develop an understanding for what sits below them is it possible to communicate them. This is one goal in therapy. The emotions below the rituals want to be communicated and this requires translating them into what they really mean, the emotions underneath them that need to be talked about and shown in the right context of an individual’s life experiences. Underneath the ritual of washing of one’s hands can be the fear of an unfulfilled need or the remnant of an emotional reaction, which can be discovered and communicated in the safety of a psychotherapy session. By verbalizing and communicating experiences associated with the emotions, they can be reintegrated into one’s personal history, which makes the world subjectively a more predictable place.
Trust and confidence in oneself and others are often central issues in OCD, since we are often dealing with feared emotions underneath the compulsions and obsessions. The rituals can have a connection with negative life events, but they do not need to. For example, a rape victim may start taking very long showers with repeated ‘cleansing’ in a ritualistic fashion, that can lead to skin and health problems. However, there is probably a biological predisposition for OCD and the symptoms may be seen as a way to deal with unpleasant emotions.
Accepting oneself means looking at how it feels to be oneself, which can require overcoming fears and distracting emotions and thoughts. The path leading there requires finding out about the values, needs and aspirations one has, which can surface in one’s dreams, preferences, accomplishments and interactions with other people. Insight into them helps build confidence and trust in oneself and others, two important antidotes to OCD.
Obsessive-Compulsive Disorder (OCD) is a condition that illustrates nicely how the brain tries to deal with problems in its own way by recreating the real world in a way that makes unpleasant emotions manageable. All organisms try to avoid unpleasant situations and attract pleasant ones. However, humans have a sense of the past and a sense of the future, which is responsible for the great creative accomplishments we are capable of, but also gives rise to psychiatric conditions.
© Dr Christian Jonathan Haverkampf
This paper is solely a basis for academic discussion and no medical advice is given. Always consult a professional if you believe you might suffer from a physical or mental health condition.