They Are Getting OCD All Wrong!

Even Evidence-Based Practice Is Missing Something Crucial

Admittedly, I’m being a little dramatic here. There’s a lot that’s super helpful about evidence-based treatments, but a simple analogy helps make it easier to see what’s missing.

Whether it’s exposure-response prevention or I-CBT, current OCD treatments view OCD like a cancer. It’s a pathogen that attacks you. OCD isn’t to be trusted or trifled with, your move is to attack back and dismantle its attempts to grow and divide inside you.

These treatments are like chemotherapy, shooting back strongly at the DNA level. On the surface, that seems great—it’s killing this horrible thing that makes you doubt yourself and compulsively check, wash, count, or question!

But, that chemotherapy is also metaphorically killing all of the other healthy cells around it too. Those other healthy cells are you, and the way you inhabit and process the world. So, in order to kill the cancer, you also have to kill little bits of yourself with each treatment. Instead of leaning into your sensitivity, for example, you are asked to cultivate more and more ways to desensitize yourself. In other words, stop being you!

What if instead we looked at OCD from a different angle? Instead of as a cancer, let’s compare OCD to an autoimmune reaction.

Let’s say a person has an allergic reaction and hypersensitivity to certain conditions. The immune system ramps up in protection, and in so doing, overproduces the defenses meant to serve you. A person with OCD is extremely sensitive to their emotional environment, particularly around issues related to harm and loss of those they love. As a result, they get particularly triggered around situations that activate these feelings, and they feel for others as if it were themselves too. The boundaries between self, other, and the world are easily blurred, and soon enough, the person with OCD is lost and feeling out-of-control.

This is why I consider OCD to be more like an autoimmune reaction rather than a cancer (and keep in mind, these are analogies for the way OCD operates emotionally, the health OCD in me is reminding all out there, you are just fine medically!). Both ERP and ICBT see OCD as your imagination gone wild and unreasonable, and cannot fathom the way feelings are working within your psychological immune system. They see the symptoms as out-of-control like cancer growth, and just want to stop it.

Of course, I want that for you too! But, with one pretty important distinction.

If you’re working with an autoimmune disorder, you don’t want to be attacking it like it’s a cancer. You want to better understand what it’s trying to protect you from and why the reaction is so intensified, and how you can get into better balance based on a more holistic understanding.

Here’s an example. A client comes in with severe OCD around fears of harming her young child. She talks about how this fear ratcheted up shortly after the baby’s birth and often struck at moments of intense fatigue, the typically sleepless nights of a new mother, and the overload of needing to be ‘on’ at all times tending to and regulating that lovely little baby’s emotional needs.

She’s always been a highly sensitive and thoughtful person, and she can’t imagine having her own selfish needs of wanting space and time for her goddamn self. See, even just thinking about it, she’s getting angry and now mad at herself for being so selfish.

But, if we take a step back, and examine her feelings with the same empathy she gives her baby, we can see her psyche is trying to communicate something important. It’s not easy being so consumed with another’s needs and losing connection to your own. In fact, it’s a very human dilemma, and a pretty spot-on one to have as a new parent. The job description is about self-sacrifice and being a 24/7 emotional regulator for another being—the normal immune response in another person becomes an auto-immune response in the OCD individual.

In addition to feeling unable to get their own needs met, the person now starts to blame and shame themselves for being an unfit parent. They start to compulsively inhibit their natural tendency to start hating being such an overworked emotional regulator and start to feel even worse about themselves.

But, as in any auto-immune reaction, what if we started to help this person get a little healthier space so that she is not overwhelmed by the allergen in her environment—too much emotional availability for others, too little for herself? What if we listened to how her psyche was saying for her temperament, she could use some periodic breaks, not just with the support of somebody else but even within her own mind. She could use reminders that it is stressful, frustrating, and overwhelming having to be super empathetic for long stretches, much like the eye strain that comes from long-distance driving. What if we reminded her that it’s not only natural but understandable to sometimes feel as much ‘hate’ for having to be in this position as there is love for this wonderful creature?

There are myriad ways we can engage her OCD not just as a cancer that just needs to be zapped away, but as a messenger that the balance is off and we need to recalibrate.

Are you seeing now how the wrong model of treatment can affect things? It doesn’t matter if ERP or ICBT are evidence-based. If they fail to take in the perspective of how the disorder works and why it functions the way it does, they are missing something extremely important and essential about the full lived experience of OCD.

Drop a line with questions or comments about this piece and the ideas found here-in. I’m hopeful that we can get even more nuanced about how we conceptualize and treat OCD. You deserve to be free of doubt, worry, and pain while also being the very fullest you there is!