The fact that rumination is a compulsion is foundational to effective OCD treatment. In order to explain why, let’s start by defining our terms:
An ‘obsession’ is a distressing thought that occurs to a person. The thought is distressing because it’s associated with the possibility of making an irreversible mistake that has permanent consequences (for further discussion, see here.)
‘Compulsions’ are anything the person does to make sure they don’t make that irreversible mistake.
‘Rumination’ means trying to figure something out in order to avoid making that irreversible mistake (for further discussion, see here.)
As discussed here, when people say they are having intrusive thoughts, upon closer inspection it turns out they are ruminating. The distressing thought that occurs to the person is the obsession, but this event takes almost no time at all. Everything that follows, all mental engagement with that thought, is compulsive rumination.
Now, you might think that the question of whether rumination is an obsession or a compulsion is just a matter of semantics, but actually it has crucial, practical implications for treatment:
- First, in Exposure with Response Prevention (ERP, the treatment for OCD), patients are asked to let the obsession be there while refraining from doing a compulsion. Thus, when people mistakenly identify rumination as an obsession, they think that they are supposed to allow this thought process to persist. They therefore end up continuing to do this compulsion on purpose, and they don’t get better.
- Second, the only way to eliminate a compulsion is by making the choice to stop doing it. No other aspect of treatment will make a compulsion go away. Thus, since rumination is a compulsion, the patient has to directly eliminate it in order to get better. This might sound obvious, but many people think that some other part of treatment, such as an exposure, is supposed to somehow make the rumination go away, and that will never happen. (In ERP terms, exposure is never a replacement for response prevention.)
For both of the above reasons, it is essential that both therapists and patients understand that rumination is a compulsion. For the same reasons, it is essential that they know where the line is between obsession and compulsion: As discussed above, the entire process of mental engagement (including even directing attention toward the thought) is a compulsion. Rumination is not a stream of obsessions, nor is it a mixture of obsessions and compulsions; it is entirely a compulsion.
Realizing that virtually all thinking related to an obsession is rumination, that rumination is a compulsion, and that a person must therefore directly eliminate rumination in order to feel better is the starting point for getting better from OCD.
However, it is only the starting point. The person must still learn how to stop ruminating, since this is not intuitive for most people (and certainly not for most people with OCD). And as with any compulsion, they must also address their conflicts about stopping: on the one hand they desperately want to stop, but on the other hand they believe that something catastrophic could happen if they do so. The resources on this website will help you with these steps.
As you begin the process of getting better, keep the following in mind:
Rumination isn’t something that happens to you; it’s something you do.
And since it’s something you do, it is also something you can stop doing.
I hope you feel better soon.