There are few things like the feeling when intense worry lifts. Whatever degree of anxiety you’re feeling– whether your kid still isn't home three hours after curfew or you desperately want your favorite sports team to win– there’s real relief in its resolution.
These two situations are widely recognized, to varying degrees, as understandable causes of heightened anxiety. But other causes are misunderstood or flat-out rejected: There’s no reason he should be freaking out about the way she’s doing the dishes or Why does this even matter to you so much? Sometimes people are said to be overthinking a situation, or “just coming up with things to worry about.”
People with all kinds of so-called mental disorders are swept to the side because they don’t fit in with accepted expressions of distress. In a way this rejection is self-protective– it can be draining to acknowledge the legitimacy of a depressed friend's withdrawals, the difficulty a family member has in maintaining a job as they deal with psychotic episodes, and so on. To recognize these things fully is to admit that nobody is really in control of everything they think and feel.
When we think of obsessive-compulsive disorder (OCD), pop culture images of strange people spiraling into increasingly desperate situations might emerge. A more likely situation, though, is that you won’t be able to spot that person unless you’re very close with them. Shame is a powerful motivator, and people tend to be good at hiding things they know will be misunderstood.
Repeated attempts to mitigate distress are called compulsions when they feel unavoidable. They’re not habits, and they don’t feel voluntary. People don’t act compulsively because they enjoy doing so. And, like the withdrawals characteristic of depression, another person's compulsions can be hard to approach with empathy.
When unpleasant feelings are alleviated by a specific behavior– say, getting checked by a doctor– it becomes more likely that someone will perform that behavior again. This isn't unique to OCD; it's a natural human response, and psychologists see it as an example of both negative reinforcement and operant conditioning. In this way, compulsions evolve over time, their temporarily alleviation of anxiety snowballing on itself while they continually shift in their specifics. What starts as a voluntary, controllable behavior can morph into a compulsion through reinforcement.
Someone might start getting a physical exam from a new doctor each month, before they realize that searching for symptoms online allows them to obtain 24/7 relief. They’re responding to obsessions– intrusive thoughts, images, or urges– because those obsessions have latched on and started causing tremendous distress.
Here, the person feels incapable of accepting sudden images of dying from a serious illness whenever something looks or feels a bit different with their body. Getting a physical exam or finding new information online reassures them for a bit: this is normal, nothing bad will happen. But, in doing so, the compulsive behavior seems to legitimize the obsession: good thing I got that checked out. It’s a cruel fact: behaviors that bring temporary relief can generate long-term suffering.
The fact that other people can only witness compulsions– and not the obsessions that fuel them– makes it hard for them to understand OCD, even if they truly want to. This isn’t unique, of course, as nobody can read another person’s mind and know exactly why they’re behaving in a certain way. But we’re able to make assumptions about most behaviors: he’s straightening things before guests arrive so they’re comfortable or even impressed, she’s buying groceries to make a meal later, they’re playing soccer because they enjoy it or want some exercise.
It’s much harder for us to make a guess as to why someone would feel completely panicked until they’re able to loop back while driving to make sure they haven’t run someone over, for example. These behaviors are not rational, so to speak, and the resulting misunderstanding means people with OCD are alone until they seek help.
Compulsions, through their reinforcement of obsessions and the way they steal so much time and energy, are the core of the suffering OCD causes. In learning to resist compulsions, people can free themselves from this vicious circle. This process, called response prevention, helps people learn how to respond to unwanted thoughts without feeling compelled to behave in any particular way.
Because our instinct is to escape suffering, it’s no wonder people tend to hope OCD treatment will get rid of the excruciating thoughts that seem to make their lives so difficult. But, in the end, thoughts may prompt suffering but do not cause it. And the most effective forms of OCD treatment don’t try to change anyone’s thoughts; they aim to help people change their behavior instead. Many find that they experience the exact same thoughts after treatment– these thoughts are, however, drained of their debilitating power.
The goal of the most research-backed type of therapy for OCD, exposure and response prevention (ERP), is to stop using compulsions and get used to distress. All of this hard work is in the service of developing lifelong and widely applicable skills for responding to unwanted thoughts by… not really responding to them.