Doubting the Doubting Disease
by Jordan Levy, Ph.D.
When individuals living with Obsessive-Compulsive Disorder (OCD) enter treatment, at some point they commonly will report experiencing obsessions related to the therapist, the therapy itself or the therapeutic process. Therapy related doubts are ancillary to the fears that they are presenting with, such as a fear of germs, homicide or being responsible for a building burning down.
Patients are not always willing to initially express these accompanying obsessions and may instead express them as treatment progresses. This can be rooted in a concern for offending the therapist or that an admission of concern may alter the therapist’s conceptualization of their case. The obsessive thoughts outlined below are occasionally expressed in an off-handed or humorous way. It is likely that some patients will go through a full course of treatment without expressing these fears and that they subside through the passage of time or through building confidence in the treatment.
The purpose of this article is to shed light on these common obsessions that patients often feel are unique to only them. Unfortunately, some patients are unaware of this and will choose to forego or terminate treatment based on a variety of these fears. Outlined below is a listing of common therapy obsessions.
1) Am I doing therapy the right way?- Psychotherapy for the treatment of OCD begins with gathering all relevant information and compiling this into a specifically tailored treatment plan. Once the treatment plan has been established, many patients become consumed with the details of the therapy. The fear of doing therapy incorrectly is that the OCD will be made worse, irreparable damage will be caused, the OCD will be worse than when therapy commenced, or improvements will be unnecessarily slow. When meeting with a therapist who specializes in the treatment of OCD, it is beneficial to trust that the therapist is constructing the best possible path for success. This can be a valid fear with someone who does not specialize in the treatment of OCD, as this individual may not have the training to appropriately guide the treatment. Many patients get caught up in the minutiae and will remark, “I know I was supposed to do my therapy homework 8-10 times but I only did it 7 times yesterday. How do I know if I am really accepting these unwanted thoughts? Will therapy still work? Am I going at the right pace?” It is not uncommon for patients to be convinced that they are doing therapy incorrectly because their anxiety feels worse during an exposure (which is the purpose of the exposure). Exposure therapy (EX/RP) requires individuals to do things that will intentionally increase anxiety in the short-term in order to achieve long-term success and mastery over their anxiety. Individuals with a high degree of perfectionism tend to endorse this line of thinking. Irrational black-and-white thinking sets the stage for thinking in “right” and “wrong” terms. Living with doubt is the key to success and that extends to the fear of doing therapy incorrectly. EX/RP for OCD is a structured treatment but there is a degree of flexibility built into the plan to ensure success.
2) My therapist doesn’t know what he/she is talking about- As stated previously, when meeting with a psychotherapist who lacks the appropriate training to treat OCD, then this is an appropriate concern and it is beneficial to seek out an OCD expert. Assuming the therapist specializes in the treatment of OCD, this fear erupts from a perceived lack of understanding on the therapist’s part. Several patients have similarly noted, “you can not possibly know what this feels like so you really can not treat this.” Individuals with OCD are often frustrated and terrified that this person they are trusting to assist them face their worst fears “does not really get it.” Regardless of the therapist’s history or non-history of OCD, the variables that are most important in ensuring an understanding of OCD, are appropriate training and continued treatment experience with OCD.
3) My therapist is treating it like OCD because that is all he/she treats- “If all you have is a hammer, everything looks like a nail.” The fear is that it is not OCD but the therapist believes its OCD because that is his/her area of expertise. OCD has been referred to as the doubting disease and the primary doubt for OCD sufferers is typically whether or not it really is OCD. If it is not OCD then an individual living with OCD will conclude that they really are going to get sick from the doorknob, really are a violent sociopath or actually are in the wrong relationship. A wise therapist does not assume that someone giving themselves the self-diagnosis of OCD means that this is automatically OCD. When conducting a thorough initial intake, the process of differential diagnosis takes place and many non-OCD alternatives as well as characterological influences are considered. It is central to the recovery process that individuals living with OCD, tolerate that it may be something real but is being treated as OCD. A related concern is that I, the therapist, believe it is something else but am playing coy. This would this be unhelpful and it would be extremely unethical.
4) It’s not really OCD- Just about every individual with OCD that I have worked with believes at various points that what they are experiencing is something other than OCD. There is always at least one bit of evidence that patients will use to point to as their non-OCD truth. Patients with sexuality obsessions will say “but I really did get an erection when I was testing myself with gay porn.” Individuals with Relationship OCD remark “but I do find the fact that my boyfriend has a gross accent and below average sense of humor detestable.” Patients can spend many sessions trying to convince me that they do not have OCD. OCD is powerful, deceptive and extremely effective at convincing someone that they do not have OCD. I like to remind people that if you were absolutely convinced that you had OCD all the time, then you wouldn’t have OCD. You can never be 100% sure that what you are going through is OCD even if you read an article that describes you to the tee and you are in an OCD support group with others who are sharing very familiar stories. You may strongly believe you have OCD but the “what if” is never far behind.
5) It is OCD AND I am in the wrong relationship/really am a pedophile/may really do what I fear- Patients occasionally report that they do believe they have OCD but that a component of the OCD is “real.” This person can view their symptoms as stemming from an anxiety disorder and are willing to treat it that way but still can’t view the entirety of the disorder as illogical. This “one foot in, one foot out” mindset will only serve to further OCD’s agenda. Taking the risk that there may be a reality basis to part of the OCD is the only way to move forward in treatment. Engaging in challenging exposures requires a level of courageous risk taking that is unmatched in any other life sphere. Not knowing if you really will do the thing you fear is a major component of the exposure (and of recovery). A common exposure for the treatment of Harm OCD is sleeping with a steak knife on the bedstand. For an individual with this OCD theme, knowing that they can snap at any moment and impulsively slice and dice their wife is a great unknown for them to tolerate. In order for EX/RP to be successful, it is imperative that an individual living with OCD tolerate many unknowns. Reassurance is unhelpful and counterproductive as a treatment strategy, however I typically reassure patients at the onset of treatment, that as far I know, noone has ever acted on their fears. As there is no meaning to the specific OCD theme, there is no reason to think you will act out the fear. I frequently inform patients that the probability that they will act out on their fear is the same probability that I will act out on their fear. This demonstrates the nearly impossible odds that what they fear will ever occur.
6) I will never get better- This distressing thought can present at all stages of treatment. OCD sufferers typically try countless ways to get rid of OCD. This may include some combination of medication, yoga, talk therapy, meditation, acupuncture, holistic remedies, self-help books and online forums. Since nothing has really worked, a sense of hopelessness can continue to grow. If anything has worked it has been a momentary pocket of relief followed by the all-too-familiar cycle of unwanted thoughts, anxiety and relief-seeking behavior. EX/RP is extremely challenging and most people only enter treatment when they are at the end of their rope. It is understandable for individuals with OCD to think that nothing will help and that the situation will never improve. The fear is that EX/RP will just be the next thing to be attempted but that ultimately does not move the needle. The good news is that once the treatment phase of therapy has commenced and fears begin to be faced head on, improvements typically become apparent within a few weeks. Inevitably as more challenging fear triggers are confronted, patients will experience an episode of intense anxiety that is too much to handle in the moment. At this point, OCD sufferers may think that they are back at square one. Because the steady flow of progress has been interrupted by expected hitches in the plan, a feeling of hopelessness begins creeping in. Patients at this critical juncture will want to give up. If OCD sufferers continue to stick to the plan, treatment will continue to pay off. There will be bumps in the road but a bump in the road is just a temporary set back. While there is no cure for OCD, it can be successfully managed so that it does not impair daily life.
7) I am misleading or deceiving my therapist- A common obsession among patients is that they are intentionally or unintentionally manipulating facts to sway their therapist. Patients will remark that “you only think this is OCD because I haven’t told you everything” or “the way that I discuss my OCD makes you think it is not real.” While it is true that a therapist only knows the reality that is presented in session, this is yet another unfounded fear. Patients fear that they have pulled the wool over their therapist’s eyes or that they have unintentionally thrown their therapist off the scent of the “real situation.” This can become very concerning to patients and can lead to an appeal for further reassurance. The best chance for success is to be as open and honest as possible with the therapist even if that means sharing shameful, repulsive, immoral or unethical information. OCD will only put more importance on this information that has been flagged and attach greater anxiety to it until it has been discussed in a therapeutic context.
8) This is going to be the piece of evidence that makes my therapist realize its not OCD- During the initial and middle stages of treatment, patients often report obsessing that they will express a behavior or describe a situation that changes the therapist’s conceptualization of the case from OCD to “real.” Patients will ask me to review the limits of confidentiality or ask me if I think what they just said is OCD/its still OCD. The gulf between OCD and reality is so massive and does not hinge on one data point. These expressions in therapy can serve as further grist for the mill that can be used to the patient’s advantage.
9) I am the only one in the world like this- There is a tendency among OCD sufferers to feel alone and that the OCD theme that they are experiencing is worse than all others. There is a palpable sense of envy wherein patients will say “I wish I had any other theme.” I work with Contamination OCD sufferers who remark “Pure-O is just in your head, but I can REALLY get sick from what scares me.” A common sentiment amongst individuals with Pure-O is that “at least with contamination you get an answer whereas I have to live with the unknown 24 hours a day.” It is extremely common for individuals living with OCD to think that their OCD is the worst in the world and that they are the only one having this. I can present patients with a carbon copy description of their OCD theme and they will still find a way to separate themselves from this replica, furthering the narrative that their OCD is unique. Group therapy can be beneficial in challenging this unhelpful line of thinking.
10) I wont be able to do the therapy- EX/RP is the most effective treatment for OCD however it also the most daunting. As mentioned earlier, individuals will do anything to relieve anxiety and are often entering therapy as the last resort. Despite a willingness to enter therapy, there is often apprehension regarding the potential success that patients can experience. The fear is that the therapy may be too challenging. Often, individuals read about an exaggerated form of exposure therapy or distort it themselves. EX/RP is challenging enough on its own without distorted exposures adding to the anxiety. Embellished exposures aside, many patients will look at the top of their fear hierarchy and say “I can’t do that!” forgetting that this is a progressive hierarchy that builds upon previous successes. To combat this fear, we always start with an exposure challenge that has a high likelihood of success. Tolerating unwanted thoughts and anxiety is one of the most challenging things that an individual can do, so it is natural to feel some level of pessimism at the onset. As individuals gain traction in therapy, they see that they are capable of doing the work required to achieve autonomy from OCD and this obsession becomes naturally alleviated.
11) The therapy wont work- Occasionally, individuals with OCD believe that they are capable of engaging in EX/RP, but that it will ultimately fail and nothing will change in regards to having OCD. The imagined scenario is one in which they conquer their most feared hierarchy item but still experience incessant torturous anxiety. Feeling cursed, some individuals have noted that nothing seems to be helping so why would this therapy help? They believe that their OCD is so powerful, that it will not conform to the behavioral principles of habituation and extinction which create positive outcomes for those living with OCD. I often encourage patients to take a leap of faith that the therapy will work without knowing that it will work. It is analogous to skydiving wherein the overwhelming high probability is that the parachute will open when you jump out of the plane but you can not know that with 100% certainty that it will open until you jump.
12) The therapy will make me go crazy- EX/RP requires an individual to be at the end of their proverbial rope and to face their absolute worst fears head on. This monumental task requires every ounce of courage that one can muster. Additionally, patients are asked to periodically provoke a high state of anxiety throughout the day for an extended period of time. Facing your fears on a daily basis can provoke obsessive thoughts that this will lead to a deterioration of mental health causing one to somehow “go crazy.” OCD is an anxiety disorder and engaging in consistent exposures will not create a mood disorder such as Bipolar disorder or a thought disorder such as Schizophrenia.
13) What is my therapist going to make me do?- An important note about therapy and EX/RP in particular is that a therapist is never going to make patients do anything. At most, I will strongly encourage my patients to challenge themselves but this is never a forced exercise. Everything that we do in therapy is mutually agreed upon, fully understood and game planned. It is most beneficial to treatment that there are no surprises or off-the-cuff exposures. OCD provides more than enough unpleasant experiences. The therapist does not have to add fuel to that fire. It is important to comprehend that patients dictate the pace at which treatment progresses, not the therapist. Everybody has a differing ability to tolerate anxiety.
The above list represents a sample of frequently uttered obsessive thoughts in therapy. As always, it is recommended that the treatment principles discussed in this article be attempted under the care of a qualified mental health professional. It is important to remember that obsessive thoughts are not bizarre or unique. Hopefully, by shedding light on common therapy obsessions, OCD sufferers will feel less stigmatized and more willing to engage in the treatment process.
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