August 23, 2015
A Good Habit (Thought, Impulse) Gone Bad
We all have quirky habits. Strange and repetitive things that we do that give us a sense of order, predictability, and safety. But in some cases, these habits are tied to intense feelings of anxiety. These cases include many accounts of those who suffer from Obsessive-Compulsive Disorder (OCD). Essentially, OCD is a case of a good impulse gone bad. OCD involves a reasonable and adaptive desire that becomes grossly distorted exaggerated. In the end, OCD becomes a ruthless, tireless, and unremitting tyrant of excessive demands.
Some years ago I worked with a client (who I’ll refer to as Joe) who formerly worked as a technical writer for a computer company in Silicon Valley. His attention to detail and precise nature were perfectly fit for writing very technical manuals for a variety of electrical devices. Yet, this personal strength became a liability. Joe’s perfectionistic ways began to disrupt his daily routine. He was unable to leave his home for work without checking and re-checking all of the locks on the doors and windows. Sometimes this process took 15-20 minutes. Joe also developed compulsions involving personal hygiene. He showered and washed himself in specific and prescribed ways, otherwise he felt he was not clean. After showering, he felt the need to dry and dress himself in a specific sequence, following a rigid protocol. If one component of this behavioral chain was not properly completed, the entire sequence was repeated over again. As you can imagine, Joe’s work performance declined and he was ordered to take a leave of absence to “get over this problem.” This enforced sabbatical brought Joe to my office. He was suffering from OCD.
OCD—a cycle of thinking, feeling, and behaving.
For all of us there is a very close connection and ongoing exchange among what we think, how we feel, and how we behave. In their infancy, obsessional thoughts and compulsive behaviors can be adaptive. For instance, an accountant may double and triple check figures and sums before a federal tax return is submitted. An airline pilot may double and triple check his flight plans and cockpit instruments. In their early stages, compulsive behaviors can be helpful and adaptive. Yet, for those with OCD, these ruminative thoughts and required behaviors become internal dictators and tyrants. A strategy and approach that once served becomes a harsh slave master.
All obsessive thoughts and compulsive behaviors are driven by anxiety. Anxiety is based upon real, imagined, or exaggerated fears, threats, and concerns over potential loss. OCD sufferers engage in compulsive rituals in an effort to manage anxiety and keep the potential loss at bay.
Let’s define some key terms. OCD is a set of unwanted thinking, feeling and behaving patterns that are very difficult to control, unproductive, and stressful.
- Thinking patterns—or obsessions are senseless, unwanted, and usually unpleasant thoughts, images, and/or impulses. These unwanted thoughts intrude into a person’s mind even though they are unwanted.
- These thoughts provoke feelings of anxiety, discomfort, and fear that something bad has happened or might happen. The feelings trigger the urge to do something to reduce the anxiety and to deal with the obsessional thoughts.
- The avoidance strategies and behavioral responses/compulsive rituals comprise the behavioral patterns that people with OCD get into as they try to cope with their obsessional thoughts and attempt to restore a sense of subjective calm and safety.
The OCD Sequence
What are the factors that drive the OCD process?
First there is a trigger. This is a situation or object that (when confronted) triggers or prompts the feelings of anxiety and distress.
Second, one experiences an obsessional intrusion. This can include an unwanted thought, image, or impulse that causes distressing feelings. Usually, the obsessional themes (thoughts, images, doubts) are connected to whatever the person considers most important—the things treasured and valued. This is why obsessions are so distressing and make a person feel so uncomfortable, anxious, or unsafe. Basically, the obsessive thoughts provoke anxiety.
Third, one has the urge to avoid or escape the obsessional thought. It’s only natural to avoid what seems dangerous. Avoidance, however, only temporarily brings feelings of safety. It doesn’t permanently reduce the obsessional fear. To make matters worse, these avoidance patterns are self-perpetuating—the more they are used, the more frequent and intense they become. Avoidance is not only, but also maintains and strengthens the faulty obsessional beliefs.
Fourth comes the thought of the feared (exaggerated, distorted) and possible consequence. These are the dreadful outcomes or tragedies that a person predicts (and fears) will happen if he doesn’t do something to deal with the obsession, such as protecting himself by performing rituals, seeking assurance, or avoiding certain situations all together. The obsessional thoughts drive catastrophic interpretations and grossly exaggerated outcomes. The imagined or real threat is massively over-estimated.
Fifth come compulsive behaviors or rituals. If the seemingly dangerous object or situation can’t be avoided, the next best solution may be to perform a ritual to reduce the anxiety and get protection from the feared consequence. Essentially, compulsive rituals are attempts to reduce the anxiety. Although these approaches provide temporary relief, the rituals are not helpful as long-term solutions. The rituals provide an immediate feeling of relief or relative safety, but they are only a temporary solution. Ironically, the rituals and avoidance actually make OCD stronger. This is because rituals generally expand and take up increasing amounts of time and energy; they often reach the point of severely disrupting day-to-day life. Rather than providing relief from anxiety, they become a problem in their own right.
As an example, a person might be concerned about personal safety and order so she begins checking her doors and window locks before leaving the house. This then generalizes to checking appliances and faucets. After a while, checking these items once is not enough, several rounds of ritualistic checking are required to quell the anxiety. This progresses so the person has time to do little else beyond checking and seeking reassurance of safety. What began as a prudent behavior has grown into a dominating and relentless OCD pattern.
Sometimes the compulsion involves not only behavior but thoughts as well. These mental rituals can be easily missed by observers because they’re thoughts rather that observable behaviors. In some cases of OCD, the person begins to consider thoughts as equivalent to actions. This is referred to as “thought-action fusion.” The person experiences an intrusive (unwanted) thought about a bad deed and believes that this thought is just as bad as actually committing the bad deed. The line dividing thought and action becomes blurred. Merely the experience of having a thought sets into motion the OCD sequence.
Obsessions come in endless variety, but they cluster into a limited number of distinct categories:
- responsibility for harm or mistakes
- symmetry or order (ordering and arranging; repeating actions)
- violence and aggression
- religion and morality
Sixth—OCD sufferers tend to seek reassurance from trusted people. They seek assurance concerning their fears and imagined consequences. The goal in seeking this reassurance is not to gain new information or insight. Rather, the goal is to reduce their level of anxiety by hearing someone else (a trusted person) confirm what they’re already relatively sure about.
Cognitive Behavioral Treatment
The goal of treatment is to allow clients to navigate and adequately manage not engaging in the compulsive behavior and not obeying the obsessional thoughts, while also managing their level of anxiety. The goal is not to eliminate the fear or anxiety, but to enable the client to move ahead with day-to-day life without engaging in the ritualistic thoughts or compulsions. The CBT approach employs four key steps: 1) cognitive therapy, 2) imaginal exposure, 3) situational exposure, and 4) response prevention.
1) Treatment begins with discussions about the intensity and frequency of the obsessional thoughts, compulsive behaviors, and avoidance strategies. Clear treatment goals are agreed upon. Both the client and therapist honestly assess the treatment challenges and carefully weigh the client’s motivation/commitment to change.
2) The goal of imaginal exposure is to weaken the connection between the obsessive thoughts and feelings of anxiety and to weaken “thought-action fusion.” Clients are not asked to think of anything that they have not already thought about. “You’re already thinking these thoughts—they’re your obsessions. In this phase of treatment our goals is to help you confront these thoughts in a deliberate and therapeutic way.” Initially, these imaginal exposures occur in the counseling office. Yet, very soon the client is asked to continue with these imaging sessions at home as in-between-session homework. Over and over the client makes himself confront the thoughts/doubts/images that frighten him the most—and also hold onto those thoughts instead of trying to distract, resist, or push them away. By doing this he takes the wind out of their sails and wins the upper hand. Repeatedly facing these distressing thoughts helps him realize that he doesn’t need to control or suppress them through mental or compulsive (behavioral) rituals. Imaginal exposure increases tolerance for anxiety. Through deliberately facing distressing thoughts and purposefully holding them in his mind (without ritualizing) the client learns that anxiety won’t last forever.
3) Situational exposure involves confronting situations. For example, a client may be asked to touch objects that usually provoke fear and anxiety. With the help of the therapist, the client gradually and therapeutically confronts the objects, situations, and thoughts that trigger obsessions, avoidance, and compulsions. The exposure plan moves progressively from situations and objects that are the least fear provoking to those most fear provoking. These exposures are intentional—not accidental. And the exposures are prolonged—not brief. The exposures are long enough to allow the client to habituate to the stimuli. And the exposures are repeated—one time exposure is not enough. During these exposure episodes the client is changing how he interprets and responds to intrusive thoughts and obsessional triggers. This is when the critical change happens—because mental interpretations and behaviors are voluntary—they are under the clients’ control.
4) Response prevention means abstaining from rituals and other fear/anxiety-driven behaviors that seem to provide temporary relief but actually make OCD worse in the long run. An example of response prevention include refraining from washing or cleaning rituals so the client remains “contaminated” for longer periods of time. This allows the client to confront the triggers and purposefully remain in the feared situation long enough to see that the anxiety decreases. All the while, the client (with coaching from the therapist) calms himself by using soothing coping strategies and affirming internal dialogue.
Treatment Outcomes for OCD: CBT and Psychiatric Medications
Many studies (across age, gender, ethnicity) of exposure and ritual prevention have been conducted. Results have shown that about 65% to 75% of those treated with this CBT approach improve substantially, and most have maintained their improvement years later. Yet, in selected cases, psychiatric medication may also play a helpful role in treating OCD. Selective Serotonin Reuptake Inhibitors (SSRIs) have proven to be somewhat helpful in the treatment of OCD. These medications tend to be less effective overall when compared to CBT. Based on medical research, there is a 50% chance that a person will positively respond to such a medication. If you are one of the 50% who respond, you are likely to experience a 20-40% reduction in your obsessional and ritualistic symptoms. Unfortunately, if treatment gains are achieved, you will need to continue taking the medication to maintain these gains.
OCD and a Christian Perspective
My work with clients is informed from a perspective of Christian conviction. From this perspective, I believe that Satan (yes—I believe in forces of good and evil) is a parasite. He has never created anything, but he does distort truth and he leaches evil out of what is good. Satan is a deceiver and a destroyer of life. He takes a good and right impulse or urge and twists it into a web of suffocating and unremitting demands. He distorts God’s truth and persuades us to remain under the “law.” He convinces us that it is our performance that eases our anxieties and fears, and not God’s unmerited favor and grace.
What we believe about our relationship with God, through Christ, determines how we navigate feelings of anxiety and fear. And what we believe to be true always shows up in our behavior.
I find that the empirically based CBT approach of exposure with response prevention is consistent with a Christian perspective. For the Christian client, I can anticipate how this approach would be enhanced and empowered by God’s indwelling Spirit, His abundant provision of grace and love, and the support of an intimate and understanding Christian community. Throughout the healing process, the OCD sufferer would do well to meditate on the truth revealed in His word concerning identity and life in Him.
Summary and Resources
OCD is one of the most common and prevalent psychological/psychiatric disorders. Its course usually begins in an innocuous manner. Over time, a helpful or adaptive habit (mental or behavior) becomes grossly exaggerated and distorted. The obsessions and compulsions are fueled by anxiety and fear and they grow into a dominating and domineering force in a person’s life. The treatment approach with the best empirically supported outcomes involves exposure and response prevention. The most helpful book I’ve reviewed on the topic is, Getting Over OCD: A 10-Step Workbook for Taking Back Your Life, by J. S. Abramowitz, Ph.D. (Guildford Press, 2009).