Virtually everybody experiences unwanted thoughts from time to time, for we human beings are not always in charge of what we think. But for sufferers of Obsessive Compulsive Disorder (especially Pure Obsessional OCD), the problem is not just the presence of unwanted thoughts, but also the attention and meaning one gives to them.
OCD and Thought-Action Fusion
Obsessive Compulsive Disorder (OCD) not only produces constant mental noise and endless worry, but also often includes a cognitive process known as thought-action-fusion. The distorted thought at the heart of thought-action-fusion is the irrational assumption that just because a “bad” thought presents itself to your mind, then it is undeniably followed or accompanied by a specific “bad” action. For some, this fusion is so strong that they believe that their thoughts actually cause actions to occur. Clients who suffer from thought-action fusion often report intense fear because of their belief that their thoughts will come true. Thought-action fusion is particularly common in the Pure O variant that is colloquially known as Harm OCD. For example, a teenage girl may worry that if she has a thought of a home invasion happening to her family, then the break-in will undoubtedly occur. Or a college student might fear that he will wander out of his dorm room and harm someone without knowing it. If this student is struggling with Harm OCD complicated by thought-action fusion, he might be overcome with a debilitating belief that, because he thinks this thought, then he is almost certainly a sociopath and is likely to act on it.
In an attempt to prevent harm to themselves or loved ones, those with thought-action fusion often take on the weight of the world and compulsively attempt to be prepared for impending doom. The girl who fears the home invasion avoids spending the night out with her friends, and repeatedly does compulsive rituals in an effort to protect her family from attack. She dreads the day she leaves for college, as she will be removed from the “guard station” she operates from her childhood bedroom. The college student who fears wandering out of his dorm room in the middle of the night begs his roommate to lock him in from the outside so that there is no risk that he will get out and harm someone.
When treating clients with these sorts of obsessions, I often suggest an analogy in which I liken their thoughts and actions to those of a person who anxiously sits on their living room sofa with a fire extinguisher waiting for a fire that may someday occur. The analogy focuses on the obsessive need of the fearful individual to not only prevent a fire, but to also be prepared at all times to protect him/herself and loved ones from the potential threat of a fire. But the simple fact of the matter is that life is a risk. We cannot be prepared 100% of the time to prevent and protect ourselves and others from tragedy. There must be a willingness to take a chance and recognize that if and/or when there is a fire, that your response will be the same whether or not you have been awaiting its arrival. For clients with OCD and anxiety, a primary goal of treatment is to get up off the “couch” and embrace the possibilities, and risks, of life. Of course, this is easier said than done.
Treatment for OCD and Thought-Action Fusion
For those with OCD complicated by thought-action fusion, treatment proceeds through a structured series of steps in order to gain the insight and courage to challenge their irrational thoughts and compulsive behaviors. Cognitive Behavioral Therapy (CBT) for OCD and anxiety is a multi-modal approach which begins with focusing on the thought process itself. Using a technique called “cognitive restructuring”, clients learn to recognize their irrational thoughts, and to challenge the “bully” in their brains. They learn to respond to an irrational thought (i.e., “I may wander out and hurt someone”) with a more rational and evidence-based thought (i.e., “I have had this thought many times, and never once have I wandered out and hurt someone”).
Mindfulness Based CBT for Thought Action Fusion
When clients can begin to effectively recognize their distorted thinking and to more actively challenge their internal mental bully, therapy proceeds to what is known as Mindfulness-Based CBT. A simple way of describing mindfulness for OCD is that it is learning the skill of non-judgmental awareness and acceptance of one’s thoughts and feelings. Using mindfulness, one learns to focus not on changing or eliminating unwanted thoughts and feelings, but rather on fully accepting their existence. After all, the thoughts and feelings are there, whether we like it or not! The ultimate goal of mindfulness for OCD and anxiety is for clients to develop their ability to fully accept the presence of their unwanted thoughts, and to recognize that just because they have these thoughts does not imply that they have meaning. A thought is not “good” or “bad”, it just “is”. In practicing mindfulness, clients work on changing their perspective towards the unwanted thoughts that plague their mind, and in turn, changing their cognitive and behavioral reaction to them.
Exposure and Response Prevention for Thought Action Fusion
When clients begin to develop the ability to truly accept their unwanted thoughts, and to recognize that these thoughts do not automatically have meaning, treatment turns to the behavioral part of CBT, which is known as “Exposure and Response Prevention” (ERP). The goal of ERP is straightforward – to expose one’s self to the feared thought or situation, without doing any compulsive or avoidant responses.
But ERP for obsessive thoughts and mental rituals is a bit different from ERP for more compulsive variants of OCD such as compulsive hand washing or door checking. Behavioral exposures for the more obsessional forms of OCD often include intentionally thinking unwanted thoughts rather than avoiding them or trying to make them go away. Not only are these unwanted thoughts purposely experienced, but short stories are created for use as imaginal exposures. For example, the girl who fears a break-in at her family home will write a short exposure story which focuses on her fear that an intruder would break in and harm her family. By writing these stories, and then reading them repeatedly, clients desensitize to the content, becoming markedly less afraid of thoughts which previously terrified them. Because of the nature of these exposure stories, this process can be quite difficult and painful for the client. But using imaginal exposures helps clients to learn four valuable lessons about their fearful thoughts:
1) When they purposely think their fearful thoughts, the feared event almost never occurs.
2) The anxiety related to their unwanted thoughts almost always decreases significantly.
3) Even if a feared event does as some point coincidentally happen to occur (i.e., sometimes homes do get broken into), it is unlikely to be as catastrophic as feared (i.e., most break-ins are committed for money, and only very rarely result in murder).
4) They are quite capable of tolerating the unwanted thoughts and uncomfortable feelings that they have avoided for so long.
In attempting to suppress a fearful thought, and avoiding specific situations as a result, the thought is only perpetuated and intensified. Conversely, it is not until the thought is faced head-on that it begins to subside. ERP is standing up to the bully that hunts for you on the playground. Rather than continuing compulsive and avoidant behaviors, and experiencing endless fear and anxiety, you confront the bully and put the bullying to a stop. In intentionally thinking a fearful thought, one is saying “I’m not afraid of you! In fact, I’m coming to find you!”. The girl who avoids leaving the house is now able to sleep over at a friend’s home, and the college student stops asking his roommate to lock him in their dorm room. At first, they may be fearful that there will be an intruder, or that they might wander out and harm someone, but as time passes, they learn that constantly protecting themselves and others from harm is not necessary. Each morning when they wake up, they find themselves and others safe and become more willing to embrace the risks of life. They no longer need to sit on the sofa waiting for a fire to start.
•Laura Yocum, MFT, is a licensed psychotherapist at the the OCD Center of Los Angeles, a private, outpatient clinic specializing in Cognitive-Behavioral Therapy (CBT) for the treatment of Obsessive-Compulsive Disorder (OCD) and related conditions. In addition to individual therapy, the center offers six weekly therapy groups, as well as online therapy, telephone therapy, and intensive outpatient treatment. To contact the OCD Center of Los Angeles, click here.