Obsessive-Compulsive Disorder can manifest in a wide variety of forms and intensity specific to the sufferer’s emotional and/or neurological structure, characterized by an experience of feeling stuck in repetitive cycles of thinking and/or behavior.
Over time, these feelings of being unable to change one’s thinking or behavior can cause escalating feelings of anxiety and depression, until life becomes unmanageable. Popularized by movies like As Good As It Gets, Jack Nicolson’s portrayal of a man who has to turn the lock on his door the same number times each time he touches it and can’t step on sidewalk cracks, is actually a pretty narrow view of the condition.
The complexities of this particular diagnosis make it essential to see a mental health professional if you are concerned about the behavior in yourself or a loved one. Because obsessive and compulsive behaviors can be somatic, neurological, or behavioral, it is important to understand the cause in order to find the best treatment. If you have received a diagnosis of OCD from a mental health professional, depending on the severity and causality, it may be treatable by Behavioral Therapy.
Behavioral Therapy for Obsesseive-Compulsive Disorder
In general, Behavioral Therapy (BT) is about using operant conditioning to alter behavior. This is done through structured interventions designed specifically for the patient sometimes using “reward” (positive reinforcement of a behavior), “punishment” (negative reinforcement of a behavior), and “extinction” (abruptly stopping a behavior) as tools to encourage desired behavior and discourage undesired behavior. Treatment plans will be developed specifically to conform to the patient’s particular strengths and interests in order to be effective.
Here are a few examples of BT in practice, to show some different applications. All subjects in the following examples are fictitious:
- A. is a 24-year-old male still living at home. His diagnosis of ADHD makes it difficult for him to get out the door in the morning to go to his college class, because he sits in his room and dwells on all the things that can go wrong. His therapist recommends he put his schedule up next to the refrigerator, to pack his backpack at bedtime and have it ready by the door, and to start setting an alarm, despite his resistance to it. With these in place, A.’s therapist works with him on redirecting his thinking away from negative potential outcomes.
- K. is 32-year-old female who got a promotion at work six months ago. She had always had a little OCD going on – touching the light switch three times before flipping it and a couple of other minor things – but nothing significant. In the past two weeks, she has noticed she is vacuuming the house a lot, to the point it is becoming her only home activity. The therapist tells her to set the timer when she vacuums and not to exceed half an hour, not to vacuum after 7pm and to ensure this by tying a red ribbon around the doorknob to the closet where she keeps the vacuum cleaner.
- B. is a 28-year-old male who can’t get a girl he dated out of his mind. She ended it without explanation after three dates and won’t return his calls. Now he is preoccupied with her, wondering what she’s thinking, what she’s doing, why she dumped him. His work is beginning to suffer and it’s been two weeks since he’s had a meaningful interaction with one of his friends. The therapist tells him to choose one of his good friends and schedule a movie or coffee, and because the thoughts of her are so persistent, to put a rubber band around his wrist and each time he thinks of her to snap his wrist lightly and redirect his thoughts, and to come up with a list of healthy activities that he can pursue to distract him from lines of thought that include her.
These are just a few examples of what a behavioral therapist might try to alter a patient’s behavior. Depending on the pathology behind the behavior, these kinds of interventions can be effective. Symptom management is only part of the equation, however. If the patient finds that anxiety ramps up significantly when the behavior is disrupted, and/or is persistently resistant to behavior modification, other avenues may have to be explored, including medication, psychodynamic psychotherapy to explore root causes, and brain testing to determine possible neurological causes.
When we are born, we are almost completely unstructured emotionally. All we have known is the warm safety of the womb. For most babies, birth is their first real traumatic experience. At the root of our response to trauma is a desire for control, in order to make the trauma stop. As infants and children, we have almost zero capacity to stop or prevent traumatic events in our lives. Depending on the severity of the trauma, we may create any of a number of defensive structures in an effort to protect ourselves.
Without any capacity to think about it – literally the neocortex has not developed enough to reason and understand our trauma – we respond reflexively depending on the intensity of the experience of trauma. A severely traumatized child may stare at the wall catatonic, disconnected from the outside world because it has proven overwhelming, or interact with a completely flat aspect, disconnected from any feeling.
One of the many possible responses to trauma is disorders of the obsessive-compulsive variety. Repetitive actions can provide us with a feeling of control over our environment, as can dwelling obsessively on a thought. By the time we reach adulthood, these defensive emotional structures are hardwired into our brains. The good news is that neurological studies have shown that we can actually rewire our brains, if we are willing to make the time and effort.
Rewiring Our Brains
When dealing with our own programmed ways of thinking, identification and awareness are half the battle. Because our defensive systems are automatic, we don’t have to be thinking about them to use them, which means if we hope to change our mode of operation, we have to make a conscious effort. This is why it’s called emotional “work” – we have to begin to hone our awareness of what is happening inside when we have an emotional response.
Suppose you see your neighbor and just seeing him or her makes you anxious. The unthinking response is to put distance between you and the neighbor. Engage your mind and ask the question, “That’s interesting, I saw my neighbor and my anxiety ramped up. I wonder what that’s about?” You might discover the neighbor reminds you of an abusive relative, or a stereotype you’ve seen on T.V., or that you felt slighted when your wave was not returned two years ago.
When you discover that your emotional response is not based on reality, i.e. the neighbor reminds you of Aunt Cruella, the next time you see the neighbor and the anxiety escalates, you can interrupt that process, engage your deep breathing to calm yourself, and say to yourself, “That is my neighbor, Sue. She is not my Aunt Cruella.”
Repeat this to yourself as you breathe, every time you notice your anxiety is up because of this process, and over time you will train yourself to be less anxious when you see the neighbor. Remember, almost everything we think about another person is made up, based on our beliefs from observation and experience. An irritated look on someone’s face can mean many things, but if we are wired to feel one down or “less than,” our default will be to imagine the irritated look is directed at us and “our fault.”
It doesn’t take much to turn an undigested morsel from lunch into an imaginary vendetta against us. There’s a story you may have heard growing up, which goes something like this. Fred needs to mow the lawn and remembers that Herb down the street has a lawn mower he could probably borrow. As he is walking to Herb’s house, the conversation in his head goes like this: “I haven’t seen Herb in a while. Now that I think about it, he probably doesn’t want to loan me his lawn mower. Herb’s pretty particular about his things. And after all the things he’s borrowed from me over the years, who does he think he is? All I want is to borrow a lawn mower for a couple of hours. What a jerk! I can’t believe he’d treat me like this after so many years.”
By now, Fred has reached Herb’s porch and rings the doorbell. When Herb answers, Fred yells, “Keep your dang lawn mower!” and storms off, leaving a bewildered Herb to watch him go. In my house, we called this “lawnmowering” – if someone chewed on an imagined offense making up bad motives about the other person without actually talking about it.
We don’t truly know what anyone else is thinking, even if they tell us. We may choose to believe them based on their behavior and demeanor, but we only believe them if we feel they are reliable witnesses. Take, for example, a father who physically abuses a child, then apologizes and says he loves them very much. What is the child supposed to believe? The remorse seems genuine. The love – in this moment – seems genuine. This is why a common defensive tool is trying to know everyone’s emotional state.
Abused children sometimes get very good at reading a room and knowing who is emotionally safe and who isn’t. This hyper-vigilance may be effective for a while at giving the person the illusion of control in social situations, but it is exhausting and gets in the way of true intimacy and healthy emotional growth in relationships with loved ones. So, to begin to unravel the complexities of our emotional grid and defensive structures with a therapist, the first steps will involve awareness of what is happening in our body in response to emotions and what some of the triggers are.
Once we begin to develop some internal awareness, especially the capacity to pause and ask, “I wonder what that’s about?” we can begin to get some understanding around these things through reflection. This is best accomplished with a therapist, who can guide us through the more painful parts of our narrative, as it is our trauma that is likely to be the most powerful motivator in our emotional responses and defenses.
Think of your unprocessed trauma narratives as furniture in your emotional living room, covered with a sheet. You can’t really see it, so you keep bumping into it (when triggered by events or people). In therapy, you can begin to remove the sheets, understand what the furniture looks like, and even have a place for it, so it’s not in the middle of the room where you keep tripping over it. Our trauma narratives never go away – they are a part of our story – but we can save ourselves from stumbling in the dark around them, and image them appropriately where they belong, in the past.
So, we recognize an emotional trigger, “Hey, I heard that song and my anxiety went up. I wonder what that’s about?”, then we reflect on it, “I remember that song was playing at that party in 5th grade when that bully humiliated me.” Once we have some room around it because we understand it, we can redirect by acknowledging and speaking truth about it: “That was a very painful experience, but it happened a long time ago, and it isn’t happening now.”
Recognize, Reflect and Redirect can be a useful tool for traumatic triggers that are relatively mild. The more profound the trauma, the more likely it will take time and professional help to work through it.
Behavioral Therapy can be an excellent tool for managing undesirable thought patterns and behavior, including OCD. Self-diagnosis may be tempting, but is not a good idea. It is best to find a therapist, get a professional diagnosis, and begin working through a treatment plan. Emotional growth and health is often possible, but we don’t know until we try.
“Tied in Knots,” courtesy of waferboard, Flickr CreativeCommons (CC BY 2.0); “Frustration,” courtesy of Creative Ignition, Flickr CreativeCommons (CC BY 2.0); “Overcast,” courtesy of Sam Burriss, unsplash.com, CC0 License; “Alone,” courtesy of Mike Wilson, unsplash.com, CC0 License