Treating OCD when the threats are real
Several therapists recently asked me “How do I address client rumination, obsessions, and over-thinking in clients with OCD, when I can’t tell them what they’re worried about isn’t real?” Two years ago, wearing a mask and gloves in public would have been considered paranoid or anxious for all but the most immune compromised people. Fast forward to April 2020 and we’re all bleaching our groceries (hopefully we’ve stopped doing that now, right?). How do you help folks with OCD discern “normal” in a world where normal is changing?
The key to treating OCD effectively is knowing that the content of the obsessions and compulsions doesn’t really matter. The function of the thoughts and behavior and the process of OCD is what we’re targeting.
First clue: What’s the function of the behavior/thought?
I don’t know if other non-behavioral therapists do this but Acceptance and Commitment Therapists definitely do. We are looking not just at the outward behavior, but what it is doing for the individual client, psychologically. Example: Binge watching The Crown on Netflix. I may be choosing to take a day to myself to watch a favorite TV show to fill the function of relaxation, recharge, and fun. In another instance, I may be watching a TV show to forget about my troubles and avoid doing unpleasant tasks. This is the same outward behavior and two very different functions. If a client is having a thought or doing a behavior, try to understand its function to find out the answer to the next question…
Second clue: Does the behavior serve the OCD or the person?
I’ve had many clients over the years who take 30+ minutes to wash their hands after going to the bathroom. They can often do this, or walk out of the bathroom without washing hands, but they can’t do what the rest of us do, which is a 10-20 second wash with soap and a quick dry. There is no cleanliness function of this behavior and it doesn’t serve the person’s health or safety.. The behavior does not serve the person or their values, but only reinforces the anxiety.
Third clue: Is the behavior flexible or inflexible?
Valued behavior is usually pretty flexible. Example: I want to exercise today and I hope it will be for an hour. Something happens and I get 45 minutes in. If I’m exercising for the “right” reasons, I’m probably going to be pretty satisfied with 45 minutes of what I hoped would be a 60 minute workout. OCD behavior tends to be inflexible without a logical explanation. Fifty five minutes of a 50 minute workout will be perceived as a failure. If we get interrupted in a valued behavior, we tend to be able to pick it right back up. OCD behaviors usually have to start over from the beginning to be “right.” The more inflexible the behavior, the more likely it is to be anxiety-driven.
Treating “real threat” OCD
After we feel pretty confident that what we’re looking at looks like OCD, we want to figure out what the client’s values are for changing that behavior, even if we can’t/shouldn’t eliminate it. What does a valuable and reasonable hand washing session look like for this client? It certainly can’t look like eliminating hand-washing. Ewww!! Instead it could look like this:
It serves the function of reasonable cleanliness after using the restroom.
It serves the value of protecting self and others from germs.
We can cope with it being slightly longer/shorter with different water and soap conditions, and feel ok about making changes to the routine.
It doesn’t go on long enough to interfere with schedules, the water supply, the soap supply, skin integrity, or relationships.
The client gets to define what they think a reasonable hand washing routine would look like - not what the OCD tells them to do but what THEY think is a reasonable goal.
When threats are real, we teach clients to differentiate between OCD-driven motivation and values-driven motivation and to tolerate the anxiety that comes with disobeying the OCD-monster in favor of listening to the more reasonable, values-driven self.