Many people think that OCD symptoms are random. They are not. The goal of this article is to provide a simple framework for beginning to see the coherency in these symptoms.
The framework begins with the idea that everyone has a worst fear.
While most people would describe their worst fear in terms of a concrete event (e.g., losing a loved one, going to jail, losing all their money, getting cancer, going to hell, etc.), what they really fear the most is the emotional state they associate with that event, and their actual worst fear would be experiencing that emotional state forever.
People with OCD are afraid of making a mistake that they can’t take back, one that would lead them to experience their most feared emotional state forever. This is their Core Fear.
The person with OCD avoids doing anything that could potentially lead to their Core Fear (avoidance), and feels compelled to do things to protect themselves from their Core Fear (compulsions). OCD symptoms are thus strategies that the person with OCD uses to protect themselves from their Core Fear, whatever that might be.
The person with OCD is like someone with a gun to their head. They are so terrified of what could happen if they didn’t do these strategies that they lose any sense that they have a choice about whether they do. Put another way, they lose their sense of agency.
The person’s subjective lack of agency regarding their symptoms worsens as they’ve been doing those symptoms for a longer and longer time, because they have so many experiences of feeling as though they don’t have a choice about doing them. Furthermore, as time goes by, they may not remember what they were so afraid of (if they ever even knew). Not understanding why they’re doing what they’re doing only adds to the feeling of not having control.
OCD symptoms can be exhausting and limiting, and can cause excruciating anxiety. But perhaps the worst part of OCD is this feeling of total powerlessness to exert any control over them.
We treat OCD by restoring a person’s sense of agency, or control. Rumination-Focused ERP (RF-ERP) helps restore a person’s sense of agency by helping them to understand why they engage in their symptoms and by systematically helping them to exercise control over those symptoms.* Sometimes this requires teaching them how to exercise control (e.g., how to stop ruminating). Other times it just requires helping them to do things, or not do things, despite how terrified they are of the potential consequences.
While simple explanations leave a lot out, I hope the above will serve as a starting point for discerning the coherency in OCD symptoms. More in-depth perspectives can be found here:
Targets and Rationales for RF-ERP Exposures
Notes
* An exposure may also provide an opportunity to disconfirm an expected negative outcome of a certain behavior, but RF-ERP does not see this as the primary way that exposure works. Moreover, it is not always possible to prove that doing X won’t lead to Y. In RF-ERP the primary goal of exposure is to learn that you have a choice, regardless of the outcome.