If you are familiar with Obsessive Compulsive Disorder- perhaps you live with the diagnosis yourself- you are likely aware that the golden standard treatment for OCD is a cognitive behavioral approach called Exposure/ Response Prevention. I’ve spoken about E/RP at length in previous blog posts and cannot emphasize enough the importance of this intervention for managing symptoms of OCD and learning to live with uncertainty. It works on changing the neural networking of the disorder much more quickly and effectively than other modes of psychotherapy, and gives the OCD sufferer the freedom to reacquaint themselves with the expansive person beneath the disorder.
In my own journey with OCD and with a few clients I’ve seen for OCD treatment, I’ve found that there’s a point beyond E/RP wherein we may be ready for a deeper level of healing and understanding of ourselves. When, and if, one arrives at this point, it’s helpful to integrate other frameworks into psychotherapy.
OCD is what the DSM classifies as a “biologically based” disorder, meaning there is a chemical predisposition for the OCD cycle in most sufferers. But there is typically more going on. The predisposition for OCD may be activated in childhood by the child’s environment, a significant life event, or the beliefs and culture of the family of origin. It may be activated in adulthood by a personal trauma, change in lifestyle, or change in environment. This is called the diathesis-stress model and is widely accepted even in behavioral or cognitive-behavioral approaches. The dynamic therapies support the same idea, but express them in a slightly different language.
What might drive a child to seek the kind of certainty we OCD types are always fruitlessly striving for? Consider this scenario: a household with a rigid set of rules. Maybe the family is religious, maybe they revere professional achievement or hold some other specific ideal in high regard. Maybe the household has stringent standards for cleanliness and order. Regardless of the values the family is organized around, falling short of the established standards is felt to be unacceptable to the children living in it. These children might hear “that’s not something a nice girl does” in response to some minor trespass, or “you know better than to wear those shoes in the house, it’s filthy outside.” As psychologist psychoanalyst Nancy McWilliams points out, this type of culture mirrors the conservative society in which Sigmund Freud first observed obsessive compulsive behaviors and has much to do with inherited feelings of guilt, shame, and feeling fundamentally unacceptable to the family or the larger system espousing these ideals. Fear, the signature emotion associated with OCD, is therefore secondary. Fear develops in response to the threat of being deviant or outcast.
Now consider a household in which the resident adults aren’t quite fulfilling their roles. Perhaps the house is chronically messy or dirty. Perhaps there is no consistent routine for getting to school in the morning or around evening meals. There may be few rules, and the rules there are may be laxly enforced. Children developing in this kind of environment may need to take on a lot of their own parenting and may need to turn to internal sources for clarification about what is acceptable and unacceptable, and to put some order to their chaotic environment.
Both of the situations described above have been associated with obsessions and compulsions in analytic literature, and both are frequently found to be the precedents in place for a strong superego (the part of the personality that determines morals and ethics—the internalized authority figure). Freud theorized that OCD, which went by other names at the time, developed as a defense mechanism against the unconscious anxiety that occurred when a person’s Id (the part of the personality comprised of primal instincts and urges) is overcontrolled by the superego. Obsessions and compulsions were understood as the superego’s efforts to assert control over the id.
The verbiage of the psychoanalytic conceptualization of OCD might feel far-fetched to you. That’s fair and expected. Mental health care today generally speaks the language of the medical model, which criticizes Freud for focusing too much on unconscious conflicts and psychosexual development. However, I think that understanding OCD- and any anxiety disorder- as defensive can be an active help in healing and growth.
Consider it: what are the themes that OCD develops around? When do obsessions and compulsions flare up? What is the ultimate goal of ERP? The OCD conceptualization process in therapy aims to make sufferers more aware of the areas in which they cannot tolerate uncertainty—in other language, the areas in which their internalized authority figure is trying to overcorrect. The treatment process aims to make sufferers tolerant of ambiguity (frequently moral ambiguity) and alert to the present moment, a kind of rebalancing of the id and superego. When understood from this perspective, OCD is simply defending us against what is and what could be, and in its vigilance makes wild conjectures regarding what reality has in store for us.
In the later stages of E/RP or after exposure work has concluded, try noticing when your anxiety disorder is keeping you out of the present moment. Ask yourself why—why would part of me want to escape this moment? What would I find if I were truly present right now? What is my OCD obscuring? Addressing these questions thoughtfully and with self-compassion will doubtless lead you down a new road of self-discovery.