The paradoxical nature of OCD treatment
I love this show and this character. Minus the smoking and drugs, she sounds like my internal monologue.
My husband is really good at digging deep for answers in conversations. Perhaps it’s my ADHD or or that my whole family communicates like this but I often talk like Nadia from Russian Doll - fast and with half the information you need to form a clear picture and I expect you to fill in the blanks. (I’m working on it and apparently at work, I pull it together and can be super clear - sorry friends and family). So I was thankful (and kind of annoyed) when he asked me to explain why OCD therapy is the “opposite” of what a lot of other therapists were taught to do in their trainings.
Your instincts got you here and they’re wrong
In a lot of therapy, therapists work to help clients listen to their inner voices and trust their instincts. But the truth about OCD is that what your mind has told you about how to “feel safe,” is actually making you less psychologically healthy/flexible, less able to engage in important things in your life, and are quite likely, the anxiety has no deeper meaning. Your mind is striving in a very ineffective way, to prove that an inherently unsafe and uncertain world is safe a certain. This is why you can logically convince yourself that you’re 99.9% safe in a given situation and still feel awful and anxious. The OCD part of your brain always says “But there’s always that .1% chance.”
Soothing and smoothing are counterproductive
OCD therapy is really challenging and while I definitely support my clients through this hard work and encourage HEAVY self-compassion as we go about it, I’m not here to collude with the OCD and make you “feel better” in the moment. The “right” thing to do is to help you sit in the uncertainty, icky feelings, dread, fear, and urge to do something ineffective to soothe yourself, and cheer you on. We’re going to sit in the muck together and learn together until anxiety doesn’t tell you want to do anymore. We’ll do this in a way that’s collaborative and gradual so it’s not torturous but it’s not going to be easy. It’s kind of like surgery - the surgeon is going to cut you to fix something. In any other context, cutting you would be assault. But in the case of OCD therapy, we’re doing tough and painful things together so you can have the flexibility to get your life back!
We’re going to be super “inappropriate” together
Nothing unethical - don’t panic! We’re also going to be evidence-based, ethical, legal, and safe. But shit’s gonna get weird. Want to know what’s in my office? I have a ‘blood exposure kit” that’s basically a specific color of maroon Sharpie on all kinds of things - tampons, pads, bandaids, etc. It looks like dried blood. I have realistic looking bugs around here somewhere. I’ve rolled on the floor with clients, touched toilet seats with them, licked doorknobs, talked about murdering my relatives, talked about them murdering their relatives, sworn a lot, and discussed generally really disturbing things. Why!? Because OCD latches onto things that are important to concepts of cleanliness, safety, moral rightness, and other abstract concepts that intersect with disturbing material. Never will we do weird things for the sake of being weird, but we will do some pretty odd things if it helps loosen up the OCD.
OCD therapy doesn't feel very good yet it does good
And I think that’s the trouble many therapists have with evidence-based therapies for OCD. From the outside, they don’t represent why most counselors got into the field in the first place - to “help people.” They don’t look kind and especially when we describe only the mechanical part (the part of the therapy that causes change in OCD), the techniques sound straight-up mean.
It’s true, clients aren’t always leaving sessions feeling “better.” They may feel proud of themselves but not “better,” and this runs counter to how many of us are trained. So much of the ART of good OCD therapy is in delivering these really difficult interventions in highly compassionate and loving ways. Being able to balance care for the person with toughness on the symptoms requires a lot of judgment and technique that most clinicians newer to practice will have difficulty with. So if you’ve heard terrible things about CBT, ACT, ERP, and seen those techniques criticized for not being person-centered, neurodiversity-affirming, or inclusive, it’s because they’ve been implemented unskillfully. It’s not because the techniques themselves are broken.