This article is based on the concept of standing up to OCD as if it is a school bully. It introduces concepts into a well-known and widely used technique that is employed by therapists for helping those with OCD. This article is also stipulates the hard work and effort that is required by people who suffer OCD to manage this potentially crippling disorder. This article also shares true insights and realities of effectively managing OCD.
OCD is misunderstood. It is often misunderstood by the general public/the general community and sometimes even those working in the mental health sector, however it should be acknowledged that nurses and other workers indeed generally have a solid understanding of mental health problems and many workers have accurate insights into OCD, yet it can still be misunderstood by some. As a former sufferer of OCD I have seen and experienced many mis-conceptions of OCD myself as an inpatient in hospitals (psychiatric wards). It is not even easy for the sufferer themselves to understand OCD! It is difficult to know how to handle obsessions and can be extremely difficult to quench compulsions or know how to handle them too. Personally, as a person who still battles a little with obsessions and compulsions at times, I am well aware of the absurdity of OCD and how rational argument ‘should’ put OCD into perspective, but the brain in a person with OCD still seems to overbear all rational argument as the brain really does send powerful ‘false’ messages to the sufferer due to parts of the brain being out of skew (in particular the basal ganglia which is responsible for particular behaviours). How many times have I made a cup of tea or coffee and I KNOW I have put sugar etc. in, but yet uncontrollable messages tell me “have you? Have you really?” Rational argument says “yes, of course you KNOW you have”, but yet somehow the brain just does not translate this to the sufferer. How can we break the relentless, overbearing, repetitive cycle of obsessions and compulsions? Just ignore them? Just don’t do compulsions?It is sadly NOT that easy (speaking here that one’s OCD is not treated). If it was so easy, there would perhaps not be any such disorder known as Obsessive-Compulsive Disorder (well, not in a severe or extreme form anyway). It is difficult, BUT managing obsessions and compulsions CAN be achieved in time. For those suffering more severe forms of OCD it will most likely take hard work, dedication and determination to manage OCD. This is often the reality, BUT also the reality is that OCD CAN be managed. Some people with mild forms of OCD may feel ‘cured’ with some appliance of strategies that can be used effectively to combat OCD, but this article is proposed more for sufferers of the more severe forms of OCD rather than mild cases (although it relates to these cases as well).
As mentioned, OCD is misunderstood; it is mysterious and even Sigmund Freud was baffled by it (Ref TTSR). To have a higher probability of managing the relentless symptoms of OCD though, we really need to become educated and to have a good, solid awareness about this disorder. Bearing in mind that there is no substitute for PROFESSIONAL help and therapy in the form of Behaviour Therapy (and also Cognitive-Behaviour Therapy), or more specifically (for OCD) Exposure and Response Therapy (ERP) and also Cognitive Therapy (CT) along with medications, and this article is only endeavoured to help readers to understand the nature of OCD. It is NOT meant to be a substitute for professional help.
To begin with, it is well recognized that sufferers do realize or are well aware that their compulsive rituals (such as checking the oven switch dozens of times or checking the window an absurd amount of times before leaving the house) are nonsensical or meaningless, but the urge to perform compulsions is still ever-powerful. Sufferers know that their behaviours (or mental compulsions such as counting) are irrational and that they ‘shouldn’t’ be done, but the urge to perform compulsions seems just out of control. It is actually a part of the brain that ‘misfires’ and it is specifically in the limbic system which is responsible for regulating sleep cycles, appetite and the ‘fight or flight response’ that has a lot to do with how and why a person with OCD engages in nonsensical, repetitive behaviours and/or mental acts that they know are meaningless (Ref TTSR). A part of the brain known as the neo-cortex which is on the outer-surface is where a person’s ability to reason is ‘formulated’. And as the brain does not function as a congruous/congenial unit or operating harmoniously as one ‘simple’ organ, but operates with different parts in relation to different purposes such as the visual parts of the brain being in a different place to the memory parts, then the brain actually sorts out varying levels of priority or urgencies of what is going on in the brain. Surely the brain tells us to take our hand off a hot stove before reminding us to check the window before we leave the house. In the ‘OCD brain’, it gets a bit mixed-up in where the urges to check and do things is a result of the misfiring of the primitive part of the brain that regulates things such as the fight or flight response is a response initiated by a perceived threat or danger and a part of the brain functions as the catalyst to perform our fight or flight actions like an automatic response, but in the OCD brain it gets ‘locked’ and the person with OCD perceives the window as being a threat and the automatic response is to attend to the window, but the messages in the brain get jammed as in that the responses keep re-occurring. This primitive part of the brain that is responsible for this gets a bit muddled with a person with OCD in that it falsely reacts to perceived threats (such as someone climbing through the window because it was left unlocked or open), but where the other part of the brain that relates to reasoning realises that the threat (for example, the window) doesn’t really exist. People with OCD do NOT generally lose touch with reality; they know what is real and what is not. It is in the primitive part of the brain where signals are sent to the person with OCD that they must check and do things in the form of mental and/or behavioural compulsions.
Understanding that the brain misfires like this may not simply enable a sufferer to stop his or her compulsions, but it can assist with initial strategies into managing their obsessions. Logical reasoning will tell us (the person with OCD) that there is no need to check the window more than once, but it just ISN’T as simple as arguing with rationalities with a person with OCD because they really DO already know that checking the window again and again and again is absurd, irrational and senseless, but the muddled messages that they are getting actually overbears all these logical rationalisms, therefore, the sufferer yields to obsessions and frustratingly continues to engage in compulsions. Reassurance just doesn’t seem enough for those suffering OCDand alternative ways of handing obsessions are better advised than offering a person with OCD reassurance that the window is locked/closed/OK.
In saying this though, how do we manage obsessions? Do we ignore them then if irrational argument or reassurance doesn’t seem to quench the fire of obsessions? Ignoring them is also a strategy that is easier said than done for many sufferers too (more-so people who have the more severe forms of OCD). For those suffering more severe forms therapy is generally needed and this usually comes in the form of specific techniques and one of these is developed from Behavioural Therapy in the form of Exposure and Response Prevention (ERP). The aim is to prevent oneself from performing compulsions and it may sound like ignoring obsessions but as the anxiety and pain accompanies the prevention of performing compulsions it is very difficult to simply ignore obsessions. However, this is acknowledged and not ignored and with the initial help of a therapist it is sort of like ignoring the obsessions in a way that you do NOT yield to performing compulsions but you MUST grit and bear the pain that will be experienced in doing so. That is not ignored. The person with OCD is well aware of the urges to do things such as checking the window, but yet the focus of attention is then turned to something else such as your therapist asking you to perform another activity. Therefore, in a way, the obsessions are ignored, but yet they are acknowledged but the idea is to ‘side-track’ one’s thinking as to the urge to perform compulsions. In summary, what this is intended to say is that the strategy is not to say ‘come on, snap out of it; just don’t think about it; ignore it’, but more along the lines of saying ‘I know you are there,
I acknowledge you I see you and I feel you. I know you are very hard to ignore and I know by not paying you any more attention I will hurt and it will be painful. But, I CAN DO THIS and as much as I know you are there ready to pounce again, I am keeping watch and command over you now as I am not going to do what you want me to do now; I am NOT going to keep checking that window”.
This is a speciality practise that a psychologist is endowed with and qualified to perform with people with OCD, but the aim is that it is to be continued by the person with OCD alone (by homework tasks) once they have had a little guidance and practise with ERP (Exposure and Response Prevention). For now though, attention will be turned back onto rational thinking. I remember one of my most problematic obsessions that I had through 4 years of therapy was obsessions relating to wanting to check the toilet after I had been (the obsessions were multiple and related to different facets of checking such as the light switch, my ‘dress’ and much more). My therapist endlessly tried to help me with applying Exposure and Response Prevention and talking about many things about my concerns with these obsessions through the usage of Cognitive Therapy (CT) and as a last resort she tried something different. My therapist instructed me to totally exaggerate the whole situation. I had to think about the worst case situation or predicament in where the toilet was exactly what I feared. I invented a situation where the toilet stank like rotten eggs mixed with sour milk and soaked in manure (or something like that), it hadn’t been flushed at all (in fact the muck in the toilet was sitting for a week!), I had left my fly/zip completely undone/unzipped and I was wearing fluorescent orange underwear so that the whole neighbourhood could see it, my belt wasn’t done up, the light switch was on and it could catch fire, I had left mess all over the floor and somebody could also slip and bang their head or hurt themselves (let alone spreading even more germs around), there were germs all over the toilet seat and underneath it plus all over the rest of the toilet, wretched ‘fumes’ from my ‘filth’ were coming out of the toilet air-vents, the door was covered in germs because of my germ-ridden fingers and whatever else I could conjure up. What a terrible chaotic catastrophe! But, this image that I was instructed to conjure up was the exact intention of my therapist.
My therapist’s aim was to totally exaggerate the situation. To conclude, my toileting obsessions were helped immensely. It worked for me. It can be a bit like trying to rationally calm a screaming and just plain disobedient, defiant toddler. The toddler will demand attention (or his/her parents to give in to her or her). Something that is recommended by some therapists is to do the opposite; encourage the toddler ‘to do his or her best’ or scream even more and behold, the child may actually stop performing such ‘rot’. This is like my toileting obsessions were. I said “well, give me your best” and I
exaggerated the whole deal. And, to my delight, my toileting obsessions and rituals have never been the same.
The thing is that the part of the brain that is out of skew in a person with OCD wants that person to yield to it like the defiant child; to give in to its demands and reasoning with it just seems pointless (like trying to reason with a defiant and disobedient toddler). Instead of ignoring the problem, it may be better (for some at least) to acknowledge the obsessions and the ‘threats’ it poses to us. This can increase anxiety, but this also IS what happens in ERP (Exposure and Response Prevention). The person with Obsessive-Compulsive Disorder MUST endure pain and discomfort before improvement is likely to transpire. How many times may have you heard the expression ‘things will get worse before they get better?’Well, this IS usually the case with overcoming OCD in terms of management of it (that is, for those with the more severe forms of OCD).
A particular strategy that can be very useful for many sufferers of OCD is to look at OCD as a SCHOOL BULLY. It is a bully to be acknowledged and not necessarily ‘simply’ ignored (that is much easier said than done when dealing with obsessions though), but it is also like putting the bully in its rightful place. Therefore, a strategy that can help people with OCD is to say something like “I see you there and I know you want me to react to you the way you want, but you’ve now got another thing coming”. Again, this is much easier said than done and this is often where those with problematic OCD will need therapy to assist in practising to put these words into action. The action here is not yielding to obsessions. It is not necessarily ignoring them as if they are not even there, but acknowledging them and also reacting to them in a different way as to what they want us to do. Hence, the action that is desirable for a person with OCD is NOT to engage in compulsive rituals. The pain can be intense and I clearly recall ending up in tears once through my therapy while applying such procedures as the pain was so strong, BUT it carries rewards! If you have moderate to extreme OCD, chances are that you will need to endure some pain before starting to be able to manage obsessions effectively.
We can also look at OCD as a barbarian or a nemesis as this can help us to separate us as ‘normal’ people from this nemesis. Maybe we could even liken OCD as being like a sugar-daddy (showering you with ‘goodies’), but with detrimental consequences. This sugar-daddy, nemesis or barbarian wants to trick us into yielding to its demands. In OCD it is the primitive part of the brain that acts as this barbarian. The brain or barbarian is saying “come on, just check the window or that stove one more time and you will then find relief”. Yet, what it is doing is setting us up for a deeper and deeper dilemma which is going to be harder and harder to get out of. The barbarian or sugar-daddy may give you little instant ‘prize’ or relief as does yielding to obsessions by doing compulsive rituals (compulsions do give the sufferer a bit of relief…….short-term), BUT this is SO temporary and it WILL COME BACK AGAIN AND AGAIN AND IN STRONGER FORCE. A person with OCD must learn to stand up to or refuse to yield and grit and bear the pain of NOT doing compulsive rituals. This is where a therapist may be needed initially at least. The nemesis or this primitive part of the brain seduces the sufferer to yield and promises them comfort as if it’s saying ” I know you’ll feel better (or find relief) if you just check once more. It will put your mind at rest”. It fools the sufferer into thinking that this ‘relief’ will last when in fact IT WON’T! A person with OCD needs to stand up to the bully or the nemesis. Some things under other circumstances in life may be better ignored or handled in a different way, however standing up to OCD can be very, very fruitful for the person enduring it.
The next part of standing up to the bully is the essence of what sufferers are taught to do in Behaviour Therapy when it comes to terms of avoiding the ever-compelling compulsions. Obsessions are like the nemesis demanding us to submit to it, but submitting to obsessions only ultimately feeds feeds them more and more and more. We need to ‘starve’ the obsessions. This is not necessarily done by ignoring them, but acknowledging them and confronting them with saying or thinking to yourself or by basically adopting the following philosophy:
“Right bully, I know that you are there and I acknowledge that you are there to stay. I know I feel so troubled and I have not yet been able to find an answer to you. I know you are indeed powerful and a ‘worthy enemy’. I feel the pain you create for me, but I’m here to tell you now that I am stronger than you; I can bear the pain that you bring. I know you want me to check that window or that stove or wash my hands just one more time, and I know that if I don’t do as you demand it will be painful for me. I know by doing what you want me to do will seem to take away some of the pain. But, I am telling you that all this manipulation from you is deceitful and nothing more than a lie; it is just a cheap trick and you are a deceiver. By doing what you want me to do; by checking the window or stove or washing my hands just one more time, I am tricking myself into thinking that my pain will end. It won’t. I know it doesn’t work by doing my compulsions that you demand me to do. I know it seems to take away the pain at the time, but it only makes things worse for me in the long-run because this pain of giving in to obsessions and doing my compulsions just comes back again and again and with just as much or even more potency. You (the bully/the part of the brain that misfires) are real, but you are a trickster and a deceiver. I also know that you want to stay and I acknowledge that I can’t simply get rid of you. If I could and if it was that simple, I would have done this long before now. You are there and you are there to stay, but now I’m telling YOU that things are going to change. Yes, you’re there in my head (the bully/the ‘misfiring’ brain), but I am going to challenge YOU. Give me your best! I CAN tolerate you! I can tolerate your pain. I can tolerate not doing what you demand me to do (this refers to NOT doing compulsions). I am willing to endure even further, deeper and more intense pain and discomfort from what you cause. I am stronger and I will not submit to your pranks any more. I am going to stand up to you ‘bully’ and NOT do what you demand any more”.
To summarise the above strategy, what is suggested is:
- acknowledge the bully, the nemesis, or enemy,
- acknowlegde the pain that it creates,
- acknowledge that it is a bully that is extremely difficult to get rid of so you may have to make room for it,
- acknowledge that you can bear the pain of the bully,
- recognise that you can take and cope with even further or deeper pain and you are willing to do so,
- confront the bully.
This is now where some really difficult work begins, but if you are suffering (and literally SUFFERING) from OCD, you may NEED to endure he pain or discomfort of REFUSING TO ENGAGE IN COMPULSIVE RITUALS. This is easier said than done and it can take a lot of practise, BUT it works very often for sufferers of OCD. It is not absolutely guaranteed, but it has worked for many people and it does have a very good track-record. The practise of refusing to engage in compulsions is the essence of Exposure and Response Prevention (ERP). The ‘exposure’ element is simply being exposed to a situation which will result in the person experiencing obsessions and having urges to perform compulsions such as asking someone who washes their hands 100 times or so each day to pick up ‘dirty’ money (or something else that may be feared of being dirty or germy etc.). Obsessions will strike and the bully that they are, they will demand that the person washes their hands not once, but again and again and again. The ‘response’ element or part of the process is NOT responding and this means here that the person WILL NOT wash his or her hands. The pain; the anxiety and torment can be overwhelming and I have xperienced this on many occasions myself through therapy as a patient of extreme OCD. Therapists are skilled and very competent in knowing how to handle these situations. I know I always felt safe with my therapist even though I experienced some ‘torture’ in NOT doing my compulsions. I was not permitted to keep checking my coffee or the toilet or whatever else we were working on. Therapists are very good at knowing how to help you (or those with OCD) cope with the mental pain or processes of the bully i these times. The pain is present though at these times and it is real and also not ignored by therapists who are well aware of this. However, for those suffering clinically distressing obsessions and compulsions, we must grit and bear the pain/tolerate the pain a bit. An old expression goes ‘short-term pain for long-term gain’ and this comes into play here. The short-term pain will be more intense initially than what it would be by continuing to be plagued and tormented by compulsively responding to obsessions. The pain can indeed be very uncomfortable with initially repelling compulsive acts, but in the long-run the pain lessens and lessens and eventually the pain can become far less than what it was when we were initially standing up to the bully. It might seem easier or less painful to check that window one more time, but in the long-run, not doing so will quench the pain a lot more.
An important point to remember by not engaging in compulsive behaviours or mental rituals such as checking that the window really is shut is that you are not going to defeat the bully or nemesis directly by doing so, but you are going to starve the bully of ammunition or fuel. Therefore, you will not get on top of the bully overnight; it takes time and it takes patience. By becoming impatient, a sufferer will again fuel the bully. Standing up to the bully may appear to be as simple as saying “no, I’m not going to do those compulsions”, however, it needs to be done on a constant basis. It takes time and work. It is a constant battle especially in the initial phases. It isn’t a quick-fix and therefore a sufferer of OCD should not expect immediate results and should not expect to feel better straight away. ERP (Exposure and Response Prevention) is a great enemy of the bully and it requires that the person with OCD be patient and willing to endure pain in order to gain long-term benefit. ERP is affective and it is proven to work. This does not mean that it will work for everybody and there are reasons for that, however, it has a proven track-record of being very helpful for many and perhaps even life-saving for some. ERP also teaches the sufferer how to manage the discomfort of not performing compulsions in affective ways. Again, a therapist may be needed at least initially for practising such methods as managing the discomfort of standing up to the bully and not doing what it demands. Behaviour Therapy in the form of ERP is hard work, but the benefits are often astounding.
The idea is not to escape from the bully as we have acknowledged that the bully is there to stay (although it need not be problematic or incapacitating), but to adopt an attitude that the bully can be tolerated. Remember that the more severe forms of OCD tend to be a life-time condition and it tends to wax-and-wane. OCD is not easy to get rid of just as a person who suffers cancer can not just simply get rid of their pain and the symptoms of cancer.Yet, OCD can be managed to a large degree. Some people with mild OCD may only require some short-term therapy where-as others will need long-term therapy plus medication (not always, but often). I personally had to go through 4 years of therapy which is a substantially long time as a goal of therapy is that the person with OCD will more-or-less become his or her own therapist by putting what s/he has learnt into practise by him or herself. I have to take 60 mg/3 X 2 mg tablets (it was up to 100 mg and down to 80 mg for years, but now only 60 mg) a day of fluoxetine (an anti-depressant) for OCD which is basically still a high dosage. I have had ECT (Elctro-Conculsive Therapy), but this was for a major depressive disorder (ECT is sometimes administered to people with unremitting OCD) and I have had other various treatments including prescriptions of valium and other medication and other forms of therapy such as CT (Cognitive Therapy), Therefore, I understand that treatment can take a long time and it requires the person with OCD to remain patient and focused or determined. Having a therapist such as a clinical psychologist to help you through these times can be one of the best weapons against the bully in your mind. Remember the bully may always be there (as mental disorders such as OCD are not necessarily curable), but OCD and its bullies can be managed!