Wise Path Therapy

Joshua Ribalkin, Registered Psychotherapist, MA

Category: Uncategorized

OCD and the Trap of Reassurance: Learning to Tolerate Uncertainty

Obsessive-Compulsive Disorder (OCD) involves a pattern of unwanted, intrusive thoughts, images, or urges known as obsessions that create significant anxiety or distress. In response, a person may feel driven to engage in repetitive behaviors or mental acts, called compulsions, in an attempt to reduce that distress or prevent something bad from happening. While compulsions may provide short-term relief, they ultimately reinforce the cycle of OCD by strengthening the connection between the obsession and the need to neutralize it. Over time, this makes the obsessions feel more frequent, more believable, and more urgent, keeping the disorder going.
When I’m working with a client with Obsessive Compulsive disorder (OCD), one of the first things I do is try and provide a clear understanding of what OCD is and how it operates.  I try and make it clear that OCD thrives when a person uses reassurance strategies.  For example, if a client comes to me with a concern that they might lose control and end up harming a loved one, (often known as harm OCD), such as with a child or spouse, but has no history of doing so,  I might feel inclined to provide the client with reassurance that the likelihood of them doing so is very low.  This approach however well intentioned might create more long term problem for the sufferer as we will discuss in more depth.
Using the example of someone experiencing intrusive thoughts about losing control and harming a loved one, it can be helpful to look at what a typical OCD pattern might involve.

First, the person notices an intrusive thought, for example, an image or urge related to harming their child or partner. This thought is unwanted and distressing, and it often leads to a sharp spike in anxiety. They may begin to question what the thought means: “Why am I thinking this?” or “Does this say something about who I am or what I’m capable of?”

In response to this anxiety, the person feels driven to do something to reduce the distress or gain certainty. This is where compulsions come in. They might try to suppress or block the thought, avoid being alone with the person they fear harming, mentally review their past behavior for reassurance, or seek reassurance from others.

These strategies often work in the short term. The anxiety decreases, and the person feels some relief. However, this relief is temporary. Because the compulsion “worked,” the brain learns that the intrusive thought is important and potentially dangerous, and that it must be managed or neutralized. As a result, the thought tends to return more frequently and with greater intensity.

Over time, this creates a self-reinforcing cycle: the more the person tries to control or eliminate the thought, the more persistent and distressing it becomes. The problem is not the presence of the thought itself, but the pattern of responding to it. Breaking this cycle involves learning to experience the thought without engaging in compulsions—even though this can feel counterintuitive at first.

I try and help the client to adopt the attitude that they can learn to live with uncertainty (ex. maybe they really are a threat to their loved ones or maybe they will be infected with some disease if they don’t wash their hands excessively) because as uncomfortable and scary as it is, this provides the best long term treatment and symptom relief for the disorder.   I am more inclined then to remind the client, especially if they are looking for reassurance, that providing them with reassurance is not likely to help with their OCD,  but that accepting some uncertainty about their fears is. While it might be true that most OCD sufferers are not likely to act on their obsessive fears, it is probably not a good idea to overly emphasize this fact.  The goal here is to help sufferers to learn to accept and live uncertainty,  much like the general population does.
In fact, it is well established in the psychological literature on Obsessive-Compulsive Disorder (OCD) that most people experience random, intrusive thoughts from time to time. Thoughts about causing harm, acting out of character, or doing something inappropriate can occur in the general population without leading to distress or concern.

The key difference for someone struggling with OCD is not the presence of these thoughts, but how they are interpreted and responded to. Individuals with OCD are more likely to assign significant meaning to these thoughts—questioning what they say about their character, intentions, or potential for action. This heightened sense of importance can make the thoughts feel threatening and urgent, which in turn fuels anxiety.

In this way, it is not simply the thought itself that creates the problem, but the relationship the person has with the thought. When a thought is treated as meaningful or dangerous, it demands attention and response. Conversely, when thoughts are recognized as mental events—essentially “just thoughts”—they tend to pass more naturally without escalating into distress.

An important part of treatment, therefore, involves learning to relate to intrusive thoughts differently: noticing them without assigning undue significance, and allowing them to come and go without engaging in efforts to analyze, suppress, or neutralize them.

How Acceptance and Commitment Therapy Can Help

Acceptance and Commitment Therapy, or ACT for short, is a type of therapy which uses mindfulness techniques like diffusion in the service of living one’s values.  The idea here is that when we are struggling to stay in the present moment, for example by becoming  overly focused  on our thoughts and emotions, (what ACT calls fusion), it makes it much harder to make choices which are in line with our values or how we would like to show up in the world.    ACT provides strategies like diffusion techniques where we are able to get distance around problematic thoughts and feelings.   This in turn makes it easier to re-focus on living a life which is in line with our purpose and allows us to take steps towards who we are trying to become.    For example, if we are ruminating about some negative experience we had and it is making it harder for us to stay present and to connect with our values we could use a diffusion technique.   One diffusion technique, as there are many, is to imagine that we are putting our thoughts on a leave and then sending that leave upstream as we observe it flowing through the water.   With ACT the goal here is not to immediately get rid of our thoughts and feelings, which ACT would consider problematic, but to change how we relate to them.  You might have heard the old adage “to not let your emotions get the best of of you”.   ACT provides a method to make that reality possible.

References:

Harris, R. (2019). ACT made simple: an easy-to-read primer on acceptance and commitment therapy (2nd ed.). New Harbinger Publications.

In Defense of Mindfulness

When it comes to mindfulness there seems to be an ongoing debate in the research community, about how effective mindfulness works and how effective it is for conditions like depression,  anxiety, and stress reduction to name but a few.   Perhaps part of the issue with determining whether mindfulness can be considered an evidence based practice like Cognitive-Behavioral Therapy, or other modalities which have been studied extensively, is due to the unique qualities which mindfulness can promote and encourage in an individual which aren’t easy to measure.   For example, in my own life I have seen how mindfulness helps me to be less reactive to other people in general and to have a relationship with uncertainty which is is novel and which cannot be easily quantified or tested using normal empirical methods.

To elaborate, by noticing my uncertainty I still sense the discomfort and even have some of the previous inclinations to try and minimize uncertainty, but with mindfulness I am able to have a new experience with uncertainty which is hard to describe.  I am more aware of the real cost to my energy resources of requiring an answer to all of my uncertainties and realize how drained I feel after attempting to eliminate uncertainty.   This novel awareness at times facilitates the desire to stay present minded because of the practical value it holds for being able to accomplish certain tasks without the added strain of trying to figure out and predict the future.   Uncertainty is known in anxiety literature and research to be a key component in generalized anxiety disorder and obsessive compulsive disorder.   Having a new way of orienting towards uncertainty which does not immediately remove the fear of uncertainty but instead helps a person to become more acquainted with the here and now practical costs of deciding to try and eliminate anxiety can be highly therapeutic.   It puts a person in touch with the practical reality of continuing to try and eliminate uncertainty and to recognize the value of to learning to allow the discomfort and angst to come and go just as an individuals allow pleasant feelings and thoughts to do the same.

SOURCES:

Farias, M., & Wikholm, C. (2016). Has the science of mindfulness lost its mind?. BJPsych bulletin, 40(6), 329–332. https://doi.org/10.1192/pb.bp.116.053686

Martínez-Esparza, I. C., Rosa-Alcázar, A. I., Olivares-Olivares, P. J., & Rosa-Alcázar, Á. (2022). Obsessive beliefs and uncertainty in obsessive compulsive and related patients creencias obsesivas e incertidumbre en pacientes con trastorno obsesivo compulsivo y afines. International journal of clinical and health psychology : IJCHP, 22(3), 100316. https://doi.org/10.1016/j.ijchp.2022.100316

 

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