Sitting With the End of Our World

By: Michael Upston, LCSW

Many people who struggle with OCD talk about a sickening feeling of dread which settles into their body (often in their stomach or chest) and creates a physical and mental sensation which seems to scream out that something is, or will be, horribly wrong.  I once heard a person describe it as a feeling that he had murdered someone, he just didn’t know who or when. Truthfully it is the stuff of nightmares and those who struggle with this deserve our utmost compassion and respect.  It takes a lot of courage to live day to day feeling this way.  In my experience of working with people with OCD, this feeling is a core fear underlying and triggering the compulsions which create the symptoms of the disorder.  It is therefore this feeling that needs to be addressed - this sense that the person’s world does not have secure foundations, that (in one way or another) it will fall apart, and can only be turned “just right” through the performance of some kind of ritual.  But this leads to the question of how?  How do people living with OCD address this fear?

For many people, medication is a necessary aid, however psychological therapy is also very important, and as a therapeutic approach, exposure and response prevention (ERP) is the treatment of choice.  Implementing ERP can be complicated, but the basic ideas behind it are fairly simple.  The process is to expose the person to the anxiety provoking situation which triggers the urge to engage in compulsions and then prevent the person from acting on that urge.  The assumption being that over time the anxiety will decrease as the person realizes at an experiential level that the feared consequences are not rational, reality based concerns.  

This process provides an alternative to engaging in the ritual.  By acting on the compulsion the person is sending themselves the message that the feared consequences are real concerns, and since engaging in the ritual often reduces the anxiety in the short term, it reinforces the use of the ritual to manage the distress.  For example, let’s say while turning on a light switch someone has the thought that a loved one will die, and OCD tells that person that the only way to make sure this does not happen is to turn the light switch on again while not having this thought.  This can become a torturous process if every time the person attempts to turn on the light switch the thought that a loved one will die continues to pop into their head. As a result that person may spend an extended amount of time turning the switch on and off.  From the outside (from another person’s perspective) these actions may not make sense, however from the inside (from that person’s perspective) the actions make perfect sense.   In this case, the person is trying to save a life. The reason why it is so difficult to not act on the urge is that the stakes are too high, it is too anxiety provoking to risk not doing it.  But the problem with this is it keeps the person stuck in their symptoms.

ERP is essentially doing the opposite of what the OCD is saying to do.  While in the above example OCD tells the person to turn on the light switch without having the “negative” thought, in ERP we encourage the person to keep going and not act on that urge. This is going to feel risky, so the process needs to occur in a gradual, hierarchical manner over time.  However, in going through this process the person “retrains” their brain.  By sitting with the distress and not acting on it, people suffering from OCD can slowly break free from it as they learn that the feared consequences will not actually happen, that their world (in whatever way they feared it would) will not actually come to an end, but that their unhealthy beliefs about it just might.