OCD and the benefits of choosing to do the hardest things


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Dedicated, together with the cycling so far, to all those I try to work with, but particularly A and J.

Whats this to do with cycling?
As Ashley and I cycle down (in a zig-zag way) the length of the UK, it has given me a lot of “head space”, something which is sadly all too rare for me most of the time. In this blog I will talk about something I have been thinking about. Its not about cycling, but at the end I will go on to consider some of the parallels with our 1,300 mile OCD awareness trip. Maybe this thinking and now the blog is my bit of the awareness!

The most important aspect of treatment? Helping people with OCD to choose to change

I have been thinking a lot about how the people I try to help can get the best from treatment for their OCD, and I have, I think, been able to clarify at least in my head something which I have known for sure for a long time, and which I have found difficult to articulate. It’s to do with choice, something I have highlighted in my teaching of professionals; I commonly title my clinical skills workshops “Helping people with OCD to choose to change”.

Treatment for OCD in a nutshell

At some level, anyone who seeks help for OCD has already “chosen to change”, and that is of course a crucial start. This is usually general though, and what happens next in terms of how that change takes place is, I think, just as important.

So what do I mean?

So lets consider how good treatment (in my view at least) should work.

First, someone with OCD should meet their therapist, and by that I mean really meet them. Two people meeting, not just one person interviewing the other. Of course the therapist “assesses” the person with OCD; do they have OCD? Can they be helped? How does their problem work? What is often much less obvious is that the person with OCD is “assessing” the therapist. Are they someone they can trust with their worst fears? Can they help? How do they understand OCD as it relates to them?

All being well, the therapist and sufferer begin to find common ground for a new way of thinking about (and therefore reacting to) their particular unique pattern of OCD thinking and behaving. To do this, they negotiate what should be a “shared understanding” of the problem, what it is and how it works. I personally think that the best type of shared understanding is “cognitive behavioural”, based on the simple idea that obsessional problems begin as normal intrusive thoughts, images, impulses and/or doubts; unfortunately, for vulnerable individuals, these are misinterpreted in terms of harm and the person being responsible for preventing it. They react by trying to prevent harm, using “safety seeking behaviours”, including both avoidance and compulsions, mental arguing and so on. These reactions have the unintended effect of reinforcing the original ideas of harm and responsibility, which in turn increase anxiety, guilt and/or shame and redoubling their efforts to prevent harm, so that the things people do to deal with their obsessions (the “solution”) actually become the problem!

So, having reached a personalized understanding of how these specific mechanisms apply in an individual, therapist and sufferer spend some time discussing how this applies to their case. Perhaps their experience tells them that the new understanding is wrong? This process is based on the principle that people experiencing OCD understandably believe that they are justified in both their fears and the actions they take to deal with them. The best way to deal with such beliefs, which make sense to the sufferer, is to help them consider alternative, less threatening ways of thinking. The idea is that these different ways of thinking available to the person with OCD are contrasted as part of the discussion with their therapist. This is sometimes described as “theory A/theory B”); for example, my problem is that I am a dirty person who could dangerously contaminate myself and/or others, who therefore needs to avoid spreading contamination and decontaminate where possible (theory A). This is contrasted with theory B, which is that I am a person who values cleanliness and worries about harming others to much that I become caught up in a vicious circle where my attempt to be completely certain about being clean and not contaminating others generate doubts which increase my fears further, as part of a vicious circle. (See Challacombe, Oldfield and Salkovskis, http://www.amazon.co.uk/Break-Free-OCD-Overcoming-Compulsive/dp/0091939690 for a more complete and detailed account of how OCD works and the treatment approach).

This all sets things up for the big deal, the leap of faith, the choice.

Choices, choices

So I’m finally getting to the point here! What follows from the above, as surely as night follows day, is that the person with OCD needs to take the next step which is to choose to confront their fears. Choose. Not be backed into a corner, not to be forced or cajoled, coerced, made to feel guilty, but to choose.

When I talk about this with people I am working with, they will sometimes give examples of how exposure or behavioural experiments don’t work. Their experience tells them so. They go on to describe having unexpectedly had their obsessional fear triggered by something that happened accidentally in their daily life without any input from them, and the whole ghastly experience just didn’t help, it often just made they feel worse. Which from what I am talking about here it would, because what has happened it that they have come from a “theory A” position and danger and responsibility have both been increased. The only way forward for the person stuck in that ghastly, out of control situation is to do their best to reduce possible harm or threat or harm and find ways of reducing their personal responsibility, which usually means some kind of neutralizing/compulsive reaction, this gets the vicious circles involved in OCD throbbing away in what feels like and unstoppable way. It simply doesn’t help.

Choosing to confront your fears, with the intention of not reversing it, has a quite different and wonderful effect. It refocuses the person on theory B……my problem is being worried about this stuff. Once the decision to do this is made, it turns out to never be as bad as expected in terms of anxiety/discomfort, and it quite simply works, and works wonderfully……unless the person keeps in their mind that they could reverse it, to wash, check, neutralize, say a prayer.

I tried to describe how this worked with someone working with me recently; see if you like my description. Starting OCD treatment, I said, is like being in a boat without realizing it. So when you try to incorporate a safety hatch (“I can wash later”; “I can beg God for forgiveness later”), what you are doing is opening up a safety hatch below the waterline! What this means is that the water (the OCD fears) will rush in if you set sail (confront your OCD fears) with a safety hatch open. You will sink in your OCD fears.

So, what this means is that once treatment has begun, and you have decent levels of support from a therapist or other helpful person, you need to CHOOSE to confront your fears without any plans to reverse what you do. If you are doing it because you feel cornered or guilty, its probably not going to work. You have to square your shoulders, set your face against your fears, and be determined to defeat them, with no thoughts of surrender once you get going. If you do that in a committed and wholehearted way, all will go well. On the other hand, if you build in a return to your obsessional way of dealing with things, you will simply suffer the anxiety, discomfort and distress of confrontation without benefit in terms of breaking free from your OCD. I see this time and time again.

Sure, its ok to resist your compulsions as much as you can, better than giving up from the start. But…..that only takes you so far in my experience. And, when you can do it, it really works, and is less difficult when you get going than you anticipate.

A very sensible person with OCD summed it up beautifully for me. They said
“I have worked out that it is so much better to feel exhausted because I have been confronting my OCD all day than because I have been giving in to my OCD all day. And I have discovered that I end up less exhausted confronting it, and can see that I might get my life back that way, rather than being a continual slave to it without hope of ever regaining control of my life”.

One other thing. Forcing the person to confront their fears DOES NOT WORK. At its most obvious, I recall when I was a …ahem…very young psychologist being told in an inpatient psychiatric unit that treatment for a person with OCD on the ward was being done, and it was Exposure and Response Prevention (ERP). Didn’t seem to be working though, said the staff. Here’s how it was being done. The poor person, to their horror, was first contaminated (without their agreement). The water was then turned off in their room, so that they couldn’t wash. Guess what? It just didn’t work. That’s an obvious example, but other less obvious but still really horrible and unhelpful ways of “doing ERP to someone” come up all the time. It doesn’t matter how well meaning those who try to force ERP are, in the end it has to be that person’s choice, and if they choose not to, and understand what it means not to, then no one should ever force them. In such situations, helping them understand more fully the way the problem works is of course part of the collaborative relationship which should be at the heart of Cognitive-behavioural therapy.

So why did I think of that when I was on the bike?

Back to the bike. So I’m cycling along, thinking about two people in particular who are struggling with this; that’s A and J, to who this article is dedicated. And I know that both are working so very hard to make sense of their OCD, but struggling to deal with it because they feel that the only way is compromise; try to deal with obsessional situations as they arise by resisting a bit, washing a bit less, avoiding a bit less and so on. That’s going to be somewhat helpful in the longer term, and is fantastically brave of them, but will not in my view deal with things fully enough or soon enough. What needs to happen is that they need to go on the attack. They need to do Anti-OCD stuff, to deliberately confront their fears. They need to go to places where things they fear will be, to put things where they shouldn’t be with the clear intention of not undoing it at all in any way ever. And yes, I know that’s hard, and feels impossibly hard at times.

Now I think its really important to make sense of OCD issues by comparing it with the way things work in general. So, I thought, how about the bike ride? Firstly, lets consider why I am doing it at all, bearing in mind that this is the second time, and longer and harder in terms of the route. How about if had been persuaded, forced or even blackmailed into doing it? How would that feel? Might I want to take short cuts? Would my heart be in it? Would I really see the point?
Secondly, how about giving myself some escape options. How about if I kept reminding myself that I could give up, go home, have the rest of the time off? Maybe I could get in the van, be taken up the mountain without having to do all that effort? What would that do to how I feel about the whole thing, how able I am to tackle the tough climbs, the long days, and the awareness meetings?

Take these two things together, being forced to do it and constantly being on the lookout for how to “cheat”, and I think I would never have started, let alone got to the Borders between Scotland and England with a clear understanding that I will, whatever happens, make it to Land’s End. I have chosen to do this, and that feels right and proper, and makes it possible for me to complete it. And…each time I think about the day ahead I feel a bit of dread, and each time I complete a day I feel elated. Choosing to get rid of OCD is, I think, a bit like that.

Paul Salkovskis, Holy Island, Northumberland, Monday 17th August 2015 (day 8 of John O’Groats to Land’s End, 1300 miles altogether.

Professor Paul Salkovskis is Professor of Clinical Psychology and Applied Science. In 2010 he was appointed Programme Director for the Clinical Psychology Doctorate Programme at the University of Bath.

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