* Published December 2022
In RF-ERP, the defining characteristic of an OCD symptom is the person’s subjective lack of agency, or their feeling that they don’t have a choice about whether they engage in that symptomatic behavior (1).
According to this definition, no behavior is ever objectively OCD. Rather, it is a person’s subjective experience that determines whether what they are doing is compulsive. Indeed, the same behavior could be compulsive in one context (if the person doesn’t want to be doing it), but not compulsive in another (if they do).
As just one example, if a person wants to use a paper towel to open the door of a public restroom, this model would not see that as compulsive/avoidant as long as the person experiences themselves as having a choice about doing so (2).
An implication of the above is that in order to identify targets for exposure, we must enlist the patient’s help in demarcating the boundaries of what they do and don’t actually want to do.
For example, if a patient has a medical condition that they research compulsively, RF-ERP would not see it as the therapist’s role to tell the patient to cut all of that research out. Rather, the therapist would elicit from the patient what research the latter actually does and doesn’t want to do. Perhaps the patient will say that, for example, it makes sense to them to read certain books or check certain websites for new information each month, but that reading other websites or checking more frequently than that doesn’t actually make sense to them. In that case, only the latter behaviors would be considered compulsive and would therefore be targets for ERP.
Although the patient is the one determining what is and is not compulsive, the therapist still plays an important role in this process. For example, the therapist may collaborate with the patient on sorting through what the patient wants versus what they feel they have to do, on thinking through what is actually constructive, and on looking at the costs and benefits of a given behavior.
Notably, the idea that the patient has the final say about what to target with ERP applies no matter how extreme a behavior might be. However, even if a behavior isn’t considered compulsive and is therefore not a target for ERP, it might still be problematic and warrant other therapeutic intervention.
Separating Out Any Constructive Element
Sometimes a person has mixed feelings about whether they want to do a compulsive behavior because that behavior accomplishes or seeks to accomplish something constructive. When this is the case, it is essential to separate out the constructive element (the part the patient actually wants to do) so that the patient can let go of the rest (the part they don’t want to do).
The example above about researching a medical condition reflects this principle. Another good example of separating out the constructive element of a compulsion is decision-making. Sometimes a person really does want to spend time thinking about a decision, but finds themselves ruminating about the decision all the time, which they don’t want to be doing. In this case, separating out the constructive element might entail scheduling time to work on the decision in a constructive way (e.g., making a list of pros and cons for each option to help the person see that there are limited options, that there is no perfect option, that no new option has come along, etc.) and then making a clear decision not to work on the decision at other times.
To be clear, despite the examples above, most of the time there is nothing constructive about a compulsion. Consistent with this, most of the time there is no constructive thought process that should be separated from compulsive rumination and scheduled. Rumination won’t help you figure out your sexual orientation, if you’re schizophrenic, if you’re a pedophile, etc. So in contrast to decision-making, where a constructive thought process is possible, we would not schedule time for thinking about these things. A therapist can play an important role in thinking through what is and is not constructive.
Many people with OCD come from families where they had to submit to being controlled in some way in order to hold on to the love and care they needed. It’s an unfortunate irony that traditional ERP can sometimes collude with these dynamics by insisting that in order to remain in treatment, the patient has to do whatever the therapist tells them to. By centering agency and insisting that only the patient gets to decide what they do and don’t want to do, RF-ERP avoids reenacting these dynamics. The therapist’s role becomes one of helping the patient sort out what the patient themselves does and doesn’t want to do, and showing them that they have the choice to do or not do it.
Implications for ERP
Conceptualizing compulsion in terms of a subjective lack of agency implies that OCD should be treated by restoring a person’s sense of agency. This is a guiding principle in RF-ERP and significantly changes how exposure is done. The result is a gentler yet more precise approach to ERP, as discussed in detail here.
1. People often ask how to distinguish between compulsive rumination and other thinking. The answer is that rumination is just a term we use for compulsive thinking, so in line with the definition discussed in this article, if a person actually wants to be thinking about something, it’s not considered compulsive rumination, but if they feel like they don’t have a choice, then it is.
2. If the person doesn’t feel like they have a choice about using a paper towel but might also prefer to use a paper towel, they might want to open the door without a paper towel to establish that they have a choice, and then, from that place of agency, make a decision about whether or not they want to do that in general.