This is the article version of the talk I gave at the 2018 IOCDF. I welcome any feedback you may have, from typos to criticisms to personal stories; please do not hesitate to email me. It is my hope that together we can formulate and disseminate an effective treatment strategy for those suffering from this issue.
Our field is failing patients who suffer from compulsive rumination. We have been unclear about how to understand this thought process, and even more unclear about what to do about it.
Worse than not providing a solution, we are actually telling patients things that make their OCD worse, as I’ll discuss below.
There was a time when the field thought that this type of thinking was “obsession.” Then it was realized that there were some “compulsions” involved as well. While this was a move in the right direction, it is still not the full picture and harmfully misleading.
The reason it’s misleading is that anyone who knows how ERP works know that you are not supposed to try to stop obsessions, while you are supposed to stop the compulsions.
To my knowledge, most of our field is accepting the premise that compulsive thinking is a mixture of obsessions and compulsions, and telling patients one of two misleading things:
(1) Try to accept the obsessive thoughts (“I might be gay,” “What if there’s no God,” “I think I’m a pedophile”) without refuting them with compulsive thoughts (“You’re not gay,” “You know there’s a God because xyz,” “I’m not a pedophile, I just think kids are cute”).
(2) Don’t try to stop this thought process at all, because that would be “thought suppression.”
Here’s what’s wrong with each of these:
(1) This is literally impossible. Instead of trying not to think one type of thoughts, now you’re trying not to think the other; you’re still in your head, inside that thought process, playing ping-pong — and you’re purposely staying engaged with the thought process.
(2) This is just plain WRONG. “Thought suppression” applies to things like “Don’t think about mom dying,” “Don’t think the word fuck,” or, “Don’t think that guy is hot.” As is kind of obvious, if you try not to think about one of these, you’re literally thinking about it by trying not to think about it. Thought suppression has NOTHING to do with analytical thinking (i.e., Kahneman’s System 2). If you were staring at a math problem and I asked you not to solve it, you could easily not solve it, because you would have to make an active choice to engage your brain in trying to solve it. Compulsive thinking isn’t just a series of repetitive intrusive thoughts. It is an analytical thought process. When you are doing it, you are trying to figure something out. You’re actively enlisting your brain in solving a problem. When therapists tell patients that they can’t stop compulsive thinking, they are literally taking people who have come in because of this symptom and telling them that the way to get better from it is to keep doing it. The patients already feel like they can’t and shouldn’t stop, and this colludes with both of those wrong ideas. People in this camp often suggest using mindfulness; this vague instruction is equivalent to telling someone to use mindfulness to observe themselves washing their hands as a compulsion. Mindfulness has a role to play, but it should not be used to tolerate compulsion.
This is what’s up: The entire thought process is compulsion, from the first word to the last, and you can and should make the decision to refrain from or stop it, because if you keep doing compulsion, you make your OCD worse.
But you say you can’t stop! Here’s what’s behind that:
(1) So many confusing messages about thought suppression that have made you think that stopping is impossible and harmful.
(2) The belief that you actually SHOULD do this compulsion to protect you from the thing you’re afraid of.
We have to help you realize (1) that you can refrain from and disengage from this thought process and (2) that you need to if you want your OCD to get better. A key component in facilitating this is helping you to understand why you are telling yourself that you should do it and that it’s really important. This is greatly aided by working on understanding (1) your core fear, (2) what you are trying to figure out when you engage in compulsive thinking, and (3) how you imagine that figuring it out will address the core fear.
What’s your overall worst fear that you can trace through all of your OCD themes? This is the area where you can’t tolerate uncertainty; there are plenty of other areas of your life where you can!
Dr. Elna Yadin says that almost all OCD boils down to a few core fears:
(1) ‘Ruining’ (e.g., I’ll marry the wrong person and ruin my life, I’ll let myself enjoy looking at a man and I’ll ruin my ability to ever feel straight again, I’ll let myself lose control and I’ll do something harmful)
You can also call this ‘making a mistake you can’t take back.’
Notably, this is the true core fear of many people who will be distracted by the other options. For example, hypochondriacs are often more afraid of this than of actual suffering; in other words, they’re afraid they’ll miss something and thus allow something bad to happen.
(2) ‘Suffering’ (e.g., I’ll be unhappy forever, I’ll be in pain forever)
(3) ‘Being a bad xyz’ (e.g., a bad person, an inferior person)
(4) ‘Death’ (pretty straightforward)
In my clinical experience thus far, it seems like most people I’ve worked with are worried about ‘ruining’ or ‘being a bad xyz.’ I think these are the most common.
What are you trying to figure out?
If I’m gay, if I’m a good person, if I need to get tested for HIV or need to stop having sex, if I need to see a doctor, what might go wrong in this situation, if someone could get hurt, if I’m going to lose control right now, etc. etc. etc.
How will figuring it out address the core fear? Put another way, what is the risk that you’re taking if you give up trying to figure it out?
If you’re afraid of thinking you’re socially inept (falls under “being a bad xyz”), your figuring out will be aimed at avoiding uncertainty about this. Reviewing an awkward social interaction might be aimed at ascertaining that you weren’t awkward or that you would know what to do next time, proving that you’re not socially inept.
If you’re afraid that you’re a bad person, your figuring out will be aimed at avoiding uncertainty about this, perhaps by analyzing your thoughts and motivations, or reviewing times when you could have been nicer, or trying to figure out what it means to be a nice person.
If you’re afraid of ruining your health, you might constantly be thinking about what you eat, or paying attention to parts of your body, or considering whether you should see a doctor. You might not actually think you’re sick, but you’re afraid of missing something and regretting it later.
Indentifying the core fear helps you to identify the goal of the compulsive thinking, which helps to organize your thought process, realize you make a choice to engage in compulsive thinking with that goal in mind — and also realize that the OCD is backfiring and undermining that very goal.
Here are some questions you might have:
Isn’t this avoidance?
No. I want you to remain aware of the uncertainty without engaging in a thought process to try to do anything about it. You had a physical reaction to someone of the same sex. That happened. You felt the flash of fear. You’re already aware of the uncertainty that that brought up for you without thinking about it further. You’re not ignoring that. You’re just not allowing yourself to start analyzing it. The basic instruction is, ‘Remain aware of the uncertainty without engaging in a verbal thought process about it.’
What should I think about instead?
I don’t care. Go do whatever you want. That’s like asking what you should think about if you’re trying not to solve a math problem. Whatever you want, you’re not going to accidentally work on it, and if you start engaging in compulsive thinking due to habit, you’ll be able to stop as soon as you notice. Is that distraction? Nope, you’re taking the uncertainty with you. Compulsive thinking is avoidance. Tolerating uncertainty without resorting to compulsion is precisely what you should be doing.
Will trying not to think analytically about it make me think about it more?
No. No no no. No. No. That’s like asking if not washing your hands as a compulsion will make you wash your hands more. The opposite will happen. You will get used to not washing your hands. You will see that you don’t have to wash your hands.
But I can’t stop!
Yes you can, you just don’t truly think that you should. Ask yourself, Why do I think it’s very important to figure this out right now? What risk would I be taking if I stopped doing this? Am I willing to take this risk given that the alternative is being sick with OCD, which anyway is backfiring and leading to my core fear? Am I truly willing to tolerate uncertainty, not just pay lip service to it?
I’ve really been trying to refrain from compulsive thinking, but I’m still stuck.
I praise your efforts, but I think you’re not refraining consistently. Sometimes, people go back and forth about refraining from compulsive thinking, and doing it half the time will keep you sick. Sometimes people do it so frequently that they don’t even realize they’re doing it (e.g., just casually thinking about what it means to be a good person, or what the purpose of existence is, or what love is, or what sexual orientation is). Another issue might be if you’re not truly willing to tolerate the uncertainty. Alternatively, perhaps you’re not understanding your core fear and how it relates to the compulsive thinking; and that’s not your fault, but it’s potentially an issue to think about with a professional who gets this stuff.
The entire analytical thought process, from start to finish, is compulsion.
As soon as you are triggered, you can just refrain from compulsive thinking, as long as you’re willing to remain aware of the uncertainty (that doesn’t mean actively thinking about it, just knowing that you’re uncertain).
Thought suppression is irrelevant to compulsive thinking because it’s actually a purposeful analytical thought process.
Sometimes thinking that you shouldn’t refrain makes you feel like you can’t refrain. You need to sort out your ambivalence about refraining, and then be resolute in the decision to refrain consistently.
Work on building awareness of how many things are actually compulsive thinking, even if they’re old habit by now.
It takes time to break a habit. Practice and hang in there.