What you don’t know about OCD might not kill you, but it can make you miserable.
Like most therapists I learned enough about OCD in graduate school to know that it was “characterized by uncontrollable, recurring thoughts (obsessions) and/or behaviors (compulsions) that an individual feels driven to repeat.” And that “these intrusive thoughts and rituals are time-consuming, causing significant distress and interfering with daily life.”
Cool, got it. I looked for people who wash hands until they’re raw, have magical thoughts like “if I don’t say these words, the plane will crash”, or are obsessively afraid of illness or dying or contamination.
In the meantime I was working with patients who were so anxious and afraid. Each week we’d talk about their fears: maybe they shouldn’t have had kids, maybe they chose the wrong career, maybe they shouldn’t have asked for that accommodation, maybe holding this boundary means they’re really selfish, maybe they’re a fraud, maybe they’re not in love with their partner, maybe they are a really bad judge of character and that’s why they keep getting hurt, maybe their trauma is too big and they’ll never be able to live a normal life, maybe they should cancel their Amazon subscription because, fuck Bezos, and buying from Amazon means they’re a secretly a bad person, maybe they need to see me more frequently.
Each week, we’d look for the root of the fear, talk about what they could do about it. Then the next week, it would be a new fear. Because I love my patients (and I was afraid of being a bad therapist who was secretly a fraud), I kept doing more trainings, exploring how to bring resources and support into my sessions to help my patients feel safe and secure. I learned a lot and it made me really knowledgeable at what I do, but the fears (mine and my patients’) kept coming.
Whether you’re a therapist or not, you’ve probably experienced this: no matter what, there’s always something else to worry about. It feels impossible to truly settle in or land. You spend your life searching for something that could be big enough, safe enough, calm enough, to let you TRULY relax.
I did more research. I focused on a treatment called Inference-based Cognitive Behavioral Therapy (I-CBT). Unlike other treatments for OCD like ERP (exposure and response prevention), I-CBT conceptualizes OCD as the outcome of a flawed reasoning process. It conceptualizes obsessions as the result of an (often elegant) reasoning process and considers that if individuals are taught to recognize and understand this process, and to shift from flawed to normal reasoning, their individual fears will not only resolve but become obsolete. Even more interesting.
But where were these individuals with their flawed reasoning and inferential confusion? What does it mean to have an obsession, what OCD is, and what is or isn’t a compulsion?
I learned that it is “the nature of thoughts themselves” that makes something OCD. These thoughts are “a relentless presence” yet powerful in their “ability to adapt to personal fears and concerns and to shape a unique but equally disruptive experience within each individual.”
I learned that while obsessions are thematic, they are also vast and deeply personal. They reflect the unique concerns, lived experience, and brain of each individual. So there can be as many obsessions as there can be brains. What makes a thought obsessional is how convincing it is at signaling “danger! Something could be seriously wrong!”
I learned that a compulsion, then, is an attempt to resolve the false narrative of our fear. It is nearly always automatic and becomes a failing strategy to resolve an obsession. Compulsions are goal directed strategies with a discernible logic or purpose behind them.
When I think back on what I learned about OCD in grad school, I shudder a little bit now. OCD is, at its core, about fear, where it comes from and our relationship to the fears themselves. And while most of these fears never come true, they can make us miserable.
References:
Frederick Aardema. Resolving OCD: Understanding Your Obsessional Experience. (Volume 1). (2024)
International OCD Foundation. What is OCD. https://iocdf.org/about-ocd/
