From Both Sides of the Couch: An OCD Story
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Trigger Warning: This essay references intrusive anxious thoughts that can occur in pregnancy.
“What if I hit someone with my car and did not realize it?”
“What if I hurt my own baby?”
“How do I know I am a good person?”
“I can’t stop noticing my own breathe, and it’s driving me crazy.”
These are just a few examples of the wide variety of distressing, intrusive thoughts that can plague the minds of people with Obsessive-Compulsive Disorder.
When I was in graduate school, I learned some basics about OCD and could have chosen to do some of my training experiences in a clinic that specialized in OCD. At the time, I wasn’t interested. I assumed that exposure therapy for OCD would be repetitive, highly structured, and essentially, boring. My assumptions stemmed from the common misperception of what OCD actually looks like. So I followed my interests elsewhere, and rarely saw cases of OCD early in my career.
When I entered private practice a decade later, I began getting more and more referrals for individuals suffering from intense anxiety, emotional dysregulation, and avoidance. By this time in my career, I knew that OCD was more than just a preoccupation with germs, cleanliness, or organization. I became familiar with the wide variety of intrusive thoughts that can create the OCD cycle of distress and compulsions and started diagnosing it more often. To better help these clients, I began an intensive training in the assessment and treatment of OCD.
The more I worked with OCD and learned from the experts, the more I began reflecting on my own long history of anxiety, which began in childhood and has taken many forms over the years.
For example, at about the time I was doing this professional deep-dive into OCD, I was also recovering from my second pregnancy. Due to the level of my anxiety, pregnancy had been torturous for me. The early excitement of a positive pregnancy test was quickly replaced by an incessant fear that something was wrong with my unborn baby. The fear was intense and inconsolable. If I could not see that my baby was safe, as they were hidden away in my womb, then I could not believe that they were actually safe.
My anxiety encompassed all the more typical pregnancy worries, but I was also bothered by very specific thoughts about rare and tragic fetal conditions. I had zero evidence to suggest that anything of the sort was occurring. I also had no way of disproving it, at least until I was provided with healthy ultrasounds. But those scans were far and few between.
While other people’s brains took a benign and neutral situation and assumed that most likely all is well, my brain saw an uncertain situation and assumed the absolute worst.
I cringed every time I was asked about the pregnancy. If I responded that all was well, I felt like I was tempting fate. Everything was fine, probably. That “probably” felt like walking a tightrope, that at any moment my greatest fear could be realized. Logically, I knew it was true but emotionally, it felt like a lie.
To try to assuage my fear, I googled. I googled every ache or discomfort in my pregnant body. I lurked in pregnancy forums and read stories about other women losing their babies, comparing their symptoms and experiences to mine. I read the same information over and over again. Of course, even the most adept search engine could not give me proof that the baby was developing normally, so no amount of reassurance was enough.
Pregnancy was not the only place where my anxiety showed up, in fact, it was likely because I had a history of anxiety that I did not find what I was experiencing in pregnancy to be all that suprising. I had other fears that plagued me, and nothing helped abate them.
The discomfort lingered in the background most of the time, like a nagging hum or a loitering dark cloud. But when something happened to trigger a thought, the anxiety would hit like a punch in the gut. Like gasoline on a kindling fire, my mind would race and I would feel miserable with fear or guilt. I knew that I would lose the rest of that evening to the torrent of distress and a fog of relentless rumination, and no one would be able to soothe me. With some time, the feelings would pass and my thinking would become rational again. I could see that I had grossly over-reacted. And I was left thinking “What the hell is wrong with me?”
I was in therapy for years, talking week after week about the same bothersome thoughts. Not only did it not help, it sometimes felt like talking about these things endlessly was making it worse. My solutions were avoidance, reassurance seeking, and rumination. Sometimes my mind was so loud, I felt like thoughts would start falling out of my ears.
The more I reflected on these experiences, and struggled with my most recent obsessions, the light bulb went off. Could this be what underlies my persistent, unreasonable, and occasionally bizarre anxieties? Did I have OCD?
Do I have OCD?
OCD is defined as a cycle of persistent, intrusive thoughts (termed obsessions) that cause significant fear, guilt, disgust, or shame. In an attempt to minimize the distress, the individual with OCD engages in compulsions, which often involve reassurance-seeking, checking, researching, or behaviors intended to clean, decontaminate, or neutralize a perceived threat.
When most people think of OCD, they imagine an individual who is washing their hands until they bleed or cleaning for hours a day. In reality, OCD obsessions can present as persistent, intrusive thoughts or doubts about virtually anything, and compulsions are often hidden (happening entirely in the person’s mind).
Some common obsessions include:
Contamination; such as germs, household cleaners, or mold
Harm; such as “What if I snap and hurt my partner” or “What if I hit someone with my car by accident”
Taboo; disturbing sexual or aggressive thoughts that the person finds disgusting or frightening
Sexual orientation; in which a person persistently doubts their sexual orientation (this is different from actual exploration of one’s sexuality experienced by members of the LGBTQ community)
Health; such as cancer or Covid
Scrupulosity; with obsessions concerned with morality or meeting religious expectations
Relationships; such as “What if I’m not really in love with my partner” or “What if I cheat on my partner?”
Common compulsions include a wide variety of behaviors such as checking, researching, asking for reassurance, cleaning and hygiene rituals, or a need to have things ‘just right’.
Compulsions can also include avoidance, in which the person actively avoids situations that trigger the thoughts and fear, and mental rituals, which include mental comparisons, reviewing the past, neutralizing bad thoughts with good thoughts, or trying to predict and prepare for every possible negative outcome. Those with OCD often engage in rumination, which refers to repetitive internal dialogue that is usually disguised as “figuring it out”.
Recovery
I sought out a specialist and scheduled an appointment for a diagnosis. The clinician confirmed that I had OCD and encouraged me to see an OCD specialist for treatment. Initially, I felt some relief and excitement at having a new understanding of the distress I was experiencing. I was hopeful that a different type of treatment would help me.
However, I was also skeptical. Partly because, due to the nature of OCD, those who receive this diagnosis often have difficulty believing it.
I was also skeptical because it seemed implausible to me that I could come this far in my career and not recognize for myself what was going on. Moreover, I had worked with a few therapists over the years, and none of them had mentioned the possibility of OCD.
The more I learned about OCD, the more I realized that my experience was actually not uncommon. Research suggests that most people suffer for a decade before receiving the proper diagnosis and treatment. Many mental health professionals are not trained to assess for or treat it, or they continue to use treatment modalities that do not have empirical evidence for effectiveness with OCD.
This is particularly concerning because traditional talk therapy will often make OCD symptoms worse. When clinicians try to help clients discover the origin of their fears, problem-solve every “what if”, or provide validation and reassurance, they inadvertently end up reinforcing the OCD. Anxiety expert Sally Winston, Psy.D. termed this “co-compulsing” and it is exactly what well meaning clinicians often did with me in therapy. The result is that clients never get un-stuck from their sticky thoughts, and continue to engage in behavior that make the thoughts more likely to hang around.
The most evidenced-based treatments for OCD are rooted in Cognitive-Behavioral Therapy (CBT) and include:
Exposure and Response Prevention (ERP)
Acceptance and Commitment Therapy (ACT)
Inference-Based Cognitive Behavioral Therapy
Getting the proper diagnosis was life-changing for me. It allowed me to create a different type of relationship with my thoughts and feelings, which made space for me to actually implement the tools and strategies that I already knew from my clinical training. In trying to better support my clients, I had ended up learning how to best support myself.
The following is a list of books, podcasts, and social media that I found helpful, and that I routinely recommend to clients.
Books:
Overcoming Unwanted Intrusive Thoughts: A CBT-Based Guide to Getting Over Frightening, Obsessive, or Intrusive Thoughts by Sally M. Winston, Psy.D. and Martin N. Seif, Ph.D.
The Mindfulness Workbook for OCD: A Guide to Overcoming Obsessions and Compulsions Using Mindfulness and Cognitive Behavioral Therapy by Jon Herschfield, MFT and Tom Corboy, MFT
Freedom from Obsessive-Compulsive Disorder: A Personalized Recovery Program for Living With Uncertainty by Jonathon Grayson, Ph.D.
Podcasts:
Memoirs:
Because We Are Bad by Lily Bailey
Pure OCD: The Invisible Side of Obsessive-Compulsive Disorder by Chrissie Hodges
Pure by Rose Bretécher
Fiction:
Turtles All The Way Down by John Green
Social Media:
Alegra Kastens on IG
Amanda Petrik-Gardner, LCPC on IG
Jenna Overbaugh, LPC on IG
Chrissie Hodges on IN
If you think you have OCD, I highly recommend finding a therapist with specialized training in the assessment and treatment of OCD. You can find a list of potential therapists at The International OCD Foundation website here.
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Disclosure: Dr. Amber_Writes is a newsletter designed to be informational, entertaining, and engaging. It is not therapy. Following this newsletter does not establish a therapeutic relationship with me. Dr. Amber_Writes, and other written communication by Amber Groomes on Substack, is not a substitute for treatment, diagnosis, or consultation with a licensed mental health professional. I assume no liability for any action taken in reliance on my writing here at Dr. Amber_Writes.
so interesting that the standard talk therapy can often make things worse--I've had that experience. There was a great article in The Boston Globe today about this very subject: it's a little long for a post, but here it is:
"How I learned to live with OCD
I didn’t realize my obsessive need to analyze every passing thought was a sign of something more than anxiety.
By Rachel Leopold Robinson
As a child, I was always anxious and risk-averse. Sleepovers, field trips, stomach bugs, and the school nurse (she reminded me of stomach bugs) were just a few of the things that scared me. As a rule, I didn’t ride on roller coasters, go to overnight camp, see movies about illnesses, or watch fireworks.
Being an anxious child gave way to being an anxious adult. I constantly worried about making mistakes, undercooking chicken, and, strangely even to me, the idea that I could one day lose control and take my own life, though I desperately did not want to. My thinking was often rigid and pessimistic, and I spun endlessly on every problem and decision, hunting hungrily for an ever-elusive right answer.
Yet, in 2020, at the age of 31, when my therapist suggested I might have obsessive compulsive disorder, I was skeptical. If I had OCD, why wasn’t I washing my hands incessantly, turning the lights on and off a specific number of times before leaving the house, and organizing my desk meticulously, as I had seen OCD portrayed in the movies? And weren’t we all “a little bit OCD’’ when we planned projects carefully and insisted on the Oxford comma?
At the same time, I was dimly aware that some of my family members had OCD, and for them it was treated as a grim prognosis, eliminating hope or the expectation that they could lead a full life. I was left with the conflicting sense that OCD was no big deal, maybe even desirable — that is, until you were diagnosed with OCD, in which case it was a death sentence.
OCD, as I would learn in the following year, is neither Order Your Coffin nor Oxford Comma Disorder. It’s a painful and often debilitating condition in which persistent unwanted thoughts and feelings (obsessions) cause extreme anxiety and drive the sufferer to engage in behaviors (compulsions) in an attempt to alleviate this anxiety. Nearly everyone has intrusive thoughts from time to time, like “What if I threw myself in front of the subway?’’ or an image of your grandma while you’re having sex. The neurotypical mind will quickly dismiss these thoughts as weird or funny, requiring no further analysis, and move on. If the brain were an email platform, these thoughts would be marked spam or even missed by the recipient entirely.
But in the OCD mind, these thoughts get stuck. In keeping with the email analogy, it’s as if they’re moved from spam to your inbox and marked “important.’’ They cause extreme distress and demand analysis: “Is that true?’’ “Would I do that?’’ “What does it mean about me that I had that thought?’’ Obsessions are often about topics like violence, sex, and contamination, but they can be about anything. The topic doesn’t actually matter. OCD is a hardware problem, a snafu in how we relate to our thoughts.
The exact cause of OCD is still unknown, but research suggests that brain biology and genetics play a role. The result is a persistent, pernicious doubt that can be applied to anything and everything: Would I hurt someone? Am I a bad person? Will I fall out of love with my partner? While neurotypical people can simply accept that they cannot have the answers to these questions and trust themselves to act in accordance with their values, sufferers of what’s often called the “doubt disorder’’ are desperate for certainty.
A compulsion is anything an OCD sufferer does in an attempt to achieve this certainty and relieve the anxiety caused by obsessions. Compulsions can be physical, like checking locks, putting objects in a specific order, or the stereotypical handwashing.
They can also be mental, and thus invisible, like reassuring yourself, reviewing situations, checking feelings and sensations, and replacing “bad’’ thoughts with “good’’ ones. The common representation of OCD as a few physical compulsions, sometimes laughed off, belies what’s happening beneath the surface: severe distress that has been aptly compared to “a stabbing pain on the conscience,’’ and an urge to get rid of it so strong that it defies logic. Compulsions do relieve anxiety, but they are only a Pyrrhic victory. The anxiety always comes back because in the end, we cannot have complete certainty about anything and there is little we can control.
Although OCD is different from its typical, often cartoonish, portrayal, it is not hopeless, thanks to a treatment developed in the 1970s: exposure and response prevention (ERP). This is a type of cognitive behavioral therapy in which you deliberately put yourself in situations that provoke anxiety and then avoid responding to it with compulsions. Paradoxically, rather than fight, avoid, argue with, or push away what terrifies you the most, the treatment for OCD is to agree, lean in, go toward.
Since my diagnosis, I have done ERP, aided by medication and under the guidance of my brilliant therapist, who — by some stroke of luck, since I didn’t realize I had OCD when I stumbled into therapy in 2020 — happens to be an OCD expert. I have taken the leap to abandon familiar yet destructive thought patterns and had the exhilarating experience of feeling my brain change. I have learned to practice mindfulness, the judgment-free awareness of what is happening in the present moment, which complements ERP by reinforcing that it’s normal for our minds to be a cacophony and that we can choose which voices we pay attention to. I have learned that while each new obsession that pops up may feel unique, it is not.
It’s all just a cover of the same bad song. And by now, I know the lyrics."
Rachel Leopold Robinson is an ed tech product manager and playwright based in New York City.
This is me in a post.
My therapist often encouraged me to see the thoughts as clouds and to watch them float by.
It never felt like enough.