OCD is called the Doubting Disease for good reason, because doubt and uncertainty are, for the most part, the central theme in all kinds of OCD. While it is easy to understand this idea conceptually, it can be difficult to realize in the moment that the doubting issue has once again come up and has got you caught up in trying to eliminate the uncertainty. And it is when we get caught up in trying to eliminate uncertainty that we turn to compulsions and/or seek reassurance.
Let me give you an example. Let’s assume that we’re dealing with a client who has pedophilia OCD and worries that he/she indeed is at risk of sexually abusing a child. When this client worries that they could actually harm a child a natural response is to seek some sort of reassurance that they wouldn’t actually do this. So, this client might talk to a trusted friend, his his/her therapist, review their past history seeking evidence that they haven’t/wouldn’t do this type of thing, etc. And the search is on for finding way of feeling certain that they would never act on these thoughts. One of the devious things that OCD does, however, is make it difficult, if not impossible, to achieve this feeling state of complete certainty that one would never act on these thoughts. A compulsive cycle can get started when the client seeks certainty, is virtually always unable to get this feeling, and does more compulsions or seek more reassurance in a desperate attempt to feel certain and of course this also fails and the cycle continues until the client is exhausted and gives up the search. One of the ways this client might seek certainty is to use logic. Perhaps trying to reassure themselves that they wouldn’t act on these thoughts because they have never done so in the past. But when it comes to logic, OCD can always win because there’s always a possible exception. For example, even though this client has never in the past acted on these thoughts, how can he/she prove to him/herself (beyond a shadow of doubt) that they will not act on these thoughts in the future? If you think about it, this is an impossible task.
Clients can get caught for hours trying to analyze, figure out and somehow “prove” to themselves that they would never act on these thoughts, but virtually always these efforts are not successful and they are left at the end of the process with just as much doubt, if not more doubt, than they had when they first began and they are exhausted from the effort. Most people with this kind of OCD are understandably concerned that they could act on these thoughts. The idea of abandoning the search for certainty is rejected out of hand as completely unacceptable because it is seen as equivalent to literally taking the risk that it could be true. The idea of leaving any possible doubt that these thoughts could be true and might be acted on sometime in the future is completely unacceptable and so the client once again re-engages in the process of doing compulsions/reassurance to attempt to eliminate the doubt. Since this elimination of the doubt is never going to work the client keeps repeating a strategy that is doomed to fail.
Yet, if we understand the basic principles of exposure and response prevention (ERP – the gold standard treatment for OCD) accepting the uncertainty is precisely what must be done. Rather than seeking reassurance, using logic to prove they won’t act on the thoughts, analyzing or trying to figure out how to achieve a state of certainty that this could never happen, the treatment involves doing just the opposite. Actually allowing the thoughts to be there, acting as if they don’t mean anything, not trying to analyze or figure the thoughts out and not seeking any reassurance. Frequently clients with this kind of OCD will have developed patterns of avoiding anything that they fear might trigger their OCD such as headlines in the newspaper about a child molester who was just arrested, headlines about another Catholic priest who apparently had molested children in the past or any place where children might be, such as the children’s section of the library, toy stores, or playground areas in the park. An effective ERP program needs to address all of these areas. Examples of items in the exposure plan would be to not avoid these newspaper headlines but to actually seek them out and read them regularly. To, perhaps, read stories about actual child molesters. To go to places where children might congregate such as libraries, toy stores and parks. And while doing these exposures to allow whatever thoughts come up just to come up and not fight them or argue with them in any way. Some clients have even made audio recordings of the thoughts that troubled them and listened to this recording as they go to the library, toy store or park.
When clients are instructed to stop fighting, analyzing and seeking reassurance regarding these thoughts and start doing the types of exposure work mentioned above, it’s important that they expect to feel guilty because they aren’t actively pursuing certainty that the thoughts aren’t true. It will feel very wrong to go this route because it is seen as accepting the risk that something awful could happen and it would be their fault. It would be especially their fault because they did not do the responsible thing, i.e. figure out if the thoughts are true.
The issue of uncertainty cuts across all forms of OCD. And while OCD takes many shapes, there are four general types: checking, contamination, intrusive sexual or harming thoughts and just right OCD. When it comes to checking, the uncertainty issue is apparent when a client does something like checking the stove repeatedly before they leave for work in the morning to be sure that they haven’t left it on despite the fact that they have not used the stove in several days. Similarly, with contamination fears, uncertainty is an issue when despite having just washed their hands, the client fears that they have not washed their hands thoroughly enough and must rewash to be sure they are clean.