What is OCD (obsessive compulsive disorder)?

Obsessive compulsive disorder (OCD) is a highly distressing anxiety condition experienced by approximately 1.2% of the UK population. All types of OCD include obsessions and compulsions. Obsessions can include intrusive and distressing thoughts, images and feelings (urges). Compulsions are the actions which are carried out in an attempt to ‘get rid’ of the intrusive thoughts, obsessions and feelings, which are highly distressing to the person with OCD. OCD can eat into a person’s time, taking them away from living the kind of life that they would value. In terms of treatment, CBT for OCD is your best option for managing the condition because it helps you to tackle the thoughts and the behaviours which keep the problem going. Cognitive Behavioural Therapy has been widely researched as the most effective method for overcoming OCD.

Why have I used a ladder to illustrate? This is to draw attention to the fact that as human beings we all have the propensity to think in superstitious ways. eg. Don’t walk under a ladder or you will have bad luck. Superstitious and magical thinking has at its heart a very similar theme to OCD, that of preventing harm and bad things from happening. Magical thinking can play a part in OCD when you may come to believe that by thinking certain things, and not carrying out certain rituals that harm can be caused or prevented.

While superstitious thoughts can be normalised as part of the human experience, OCD is an anxiety problem where you may become stuck in a loop of intrusive thoughts and actions while trying to reduce the potential distress caused by believing that you may be responsible for capable of causing harm to the self or others.

In this short introduction to OCD and CBT for OCD, I am aiming to give a broad overview of what OCD is and what you may expect from CBT for OCD, but there are limitations to such a short piece. Towards the end of the article I’ll recommend a couple of excellent books for you to turn to, should you want to know more.

What is obsessive compulsive disorder?

OCD begins with a trigger situation which is closely followed by an intrusive thought or obsession. To the sufferer this is not merely a passing obsession, but one which is highly distressing or anxiety-provoking. There are certain themes which these thoughts might fall under (contamination fears, obsessions related to perfectionism, religious obsessions, unwanted sexual thoughts, fear of causing harm, or fear of losing control to give a general overview). OCD is not limited to feeling anxious, the emotions experienced as part of the problem can be many: including anxiety, shame, guilt and depression.

OCD compulsions fall into two main camps - visible (overt) and invisible (covert). When most people out there think of OCD, they think of visible actions (such as hand-washing, checking candles are out or electrical plugs off, doors and windows being locked, seeking reassurance) but just as common are invisible compulsions which are carried out in the mind of the person who has OCD. Examples might include counting, memory hoarding, reviewing events to see whether or not something happened, self-reassurance, rationalising intrusive thoughts, neutralising words, or trying to prove the thoughts untrue beyond doubt.

Each person’s OCD takes on its own unique ‘flavour’, but whichever form you have, you can be assured that in all cases, the compulsions keep the OCD going. Yes, temporarily you may feel less emotional distress when you carry out a compulsion, but in the long term these are unhelpful actions. Over time these actions can increase your distress, as they keep you locked into a battle with the OCD, limit the activities you would otherwise choose, and negatively impact close relationships.

The problem with OCD compulsions

Compulsions are behaviours which give your brain the message that the intrusive thought (or urge) you have experienced has something of note to offer you. Responding to the intrusion or the obsession with an activity (covert or overt) gives your brain the message that the thought is important. Correspondingly, your brain, will offer more intrusive thoughts as long as you continue to respond with a compulsion. The brain is so generous like that! You can kindly thank your mind for this, it really does want the best for you, it’s just being an overhelpful friend.

Everyone’s OCD is unique to them so it’s important to be clear what you are doing which might keep the problem fired up. This will be useful material in the treatment of your OCD. Treatment of OCD involves a multi-pronged approach. Understanding what OCD is and how it is maintained, learning about the nature of thoughts, relating differently to the intrusive thoughts, and (most important) learning to tolerate the uncertainty and discomfort which comes when you begin to refrain from responding to your obsession through ERP (Exposure and response prevention) are some of the ways forward.

ERP involves gradual exposure to your intrusive thoughts, so that you can begin to habituate to the discomfort you experience as you learn to refrain from the compulsions. This exposure will be through imaginary exposure and real life exposure; your plan for treatment will be quite specific to your own symptoms and behaviours. To overcome the obsessions you will need to repeatedly expose yourself to situations you fear by whilst not carrying out your compulsions. This is done in a gradual way at a pace you can handle! Over time and with repeated new actions, your obsessions and your fear should start to trouble you less.

Thoughts are just thoughts

Learning not to respond to your intrusive thoughts will be a valuable goal. In studies, we know that 90% of people have odd, strange, unwanted thoughts. (And who really knows for sure whether the remaining 10% had thoughts they didn’t want to admit.) Any thought is possible in any person, and for the most part, these intrusive thoughts don’t cause people problems, but if you have OCD and you have begun to attach layers of meaning to those thoughts, you’ll have begun to get hooked by them. What keeps you getting reeled in is acting to try to alleviate the anxiety, guilt or shame which might accompany those intrusive thoughts or urges.

Cognitive behavioural therapy means working on thoughts and behaviours. With OCD, this means that not only are we tackling the behaviours which maintain obsessive compulsive disorder, but we may also be looking at your beliefs about your thoughts and your feelings, your drive to obtain absolute certainty where you may experience a persistent sense of doubt, and a sense of overdeveloped responsibility for preventing harm. With consistent effort and practice, you can learn to manage OCD and break free of its vicious cycle. You can stop yourself getting reeled in, hook, line and sinker. You can stay on the shore and you don’t need to get into the swirling water with it.

You might also be interested in Courtroom Drama analogy for relating to your OCD in a different way.

As I finish this short intro to CBT for OCD, I’m aware this only scratches the surface of what it means to have obsessive compulsive disorder, but I hope it serves as a brief primer on what keeps this problem going and how you can begin to unravel the problem.

If you want to read more, I highly recommend the following:

Break Free From OCD by Fiona Challacombe, Victoria Bream Oldfield and Paul Salkovskis

Managing OCD with CBT (For Dummies series) by Katie d’Ath and Rob Willson

Overcoming Unwanted Intrusive Thoughts by Sally Winston and Martin Self

Ali Binns is a CBT therapist based in Bath. She helps clients to manage their anxiety and mood using evidence-based cognitive behavioural strategies. Please use the contact form if you would like to get in touch.

OCD: the Courtroom Drama analogy

If you have OCD, learning new ways of managing difficult thoughts, feelings and urges with CBT for OCD is the key to living the life you want rather than the one OCD convinces you to lead. One of the approaches we focus on in overcoming OCD with CBT is to learn to relate differently to your thinking. There are many helpful metaphors which might help you to relate differently to your thoughts, but I particularly like this one…

It might help you to imagine your OCD as something like a very experienced, driven, but flawed prosecutor in a court of law. Think back to watching American courtroom dramas at the movies or on Netflix and picture the most opportunistic prosecutor who will stop at nothing until he can prove you are guilty.

The OCD prosecutor believes you are guilty and responsible for causing harm until proven innocent. You’re in the dock and you’re on trial. You, as the defendant, naturally want to defend yourself and prove the prosecutor wrong beyond all reasonable doubt. However, whenever you do this, you are playing into the hands of the prosecutor. Your problem is that you are trying to obtain proof for something which hasn’t happened. This defence case is going to cost you, and big-time. Hours of worry, guilt, shame, wasted hours putting in the effort of trying to argue your side of the story, proving once and for all, beyond certainty that you weren’t, couldn’t be or are never capable of causing the harm or wreckless abandon you fear. The OCD prosecutor means to win, and will use every doubt-enhancing trick in the book to keep you defending. You might get temporary evidence, but very soon the OCD prosecution will come back for another round, with another witness or another event.

You may even plead the defence that “it’s not me, it’s my OCD”. Often this will create a temporary adjournment in proceedings (to continue the metaphor), but occasionally a particularly crafty prosecutor can even use this against you. “What if you don’t have OCD, and these thoughts are a sign that you are a terrible person?” Forewarned is forearmed, it is true, it’s not you, it is your OCD, but a hotshot lawyer will even try to get you to doubt the diagnosis.

Fortunately, if you watch US courtroom dramas, you’ll know there is a route out of this. You can plead the right to remain silent. By telling the prosecutor that you choose not to respond to their demands for proof that you could not or would not act in the way you fear, be what you fear, or be to blame for what you fear might happen, you give the prosecutor no more material to work with. Over time the case will fall apart. There is no evidence to be found, no certainty to be obtained. You can choose to walk away from the proceedings, knowing that you no longer have to play into the hands of the prosecution.

Of course, this isn’t as easy as it sounds, but the metaphor itself may help to remind you not to play into the hands of your OCD mind. Working alongside a CBT therapist you’ll learn strategies to take you through the changes how you relate to your thoughts and change your behaviours which will help you to manage your difficulties.

You can read a little more here: What is obsessive compulsive disorder?

Ali Binns is a CBT therapist based in Bath. She helps clients to manage their anxiety and mood using evidence-based cognitive behavioural strategies.