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Both Ends Against The Middle: When OCD Tries To Disrupt Its Own Treatment
Written by Fred Penzel   
Wednesday, 12 July 2017 23:35

Both Ends Against the Middle: When OCD Tries To Disrupt Its Own Treatment

By: Fred Penzel, PhD

Obsessive compulsive disorder (OCD) has long been known to take on many strange forms and cause people to think unusual things. It is important to know about and be able to recognize these different forms in order to make a correct diagnosis, and therefore have an effective treatment plan. In my many years of treating OCD, one of the more unusual things I have seen OCD do is actively undermine a sufferer’s attempts to get treatment. It’s not as if OCD actually has a separate intelligence of its own, although it may sometimes seem that way. One reason for this is that it seems to have an uncanny ability to home in on aspects of people’s lives that are most important to them. Since recovering is such a vital issue for OCD sufferers, it is no surprise that OCD would attach itself to their efforts towards getting well. This can unfortunately create major roadblocks in treatment, to the point of causing some sufferers to give up in frustration and conclude that they simply do not have the ability to recover.

The various ways in which OCD does this can be either very obvious and straightforward or extremely subtle and difficult to recognize. Therapists who are unaware of these types of symptoms can often be misled into believing that their patient is somehow not cooperating, or doesn’t possess the insight or motivation to get well.

Some of the things you may typically see in these cases include:

Patients thinking that they must do their therapy perfectly or else they won’t get well

This all-or-nothing thinking leads to compulsive perfectionism in carrying out therapy assignments, which can cause further problems for sufferers. One such problem is patients pushing themselves far beyond the level they are able to handle, making them so anxious that they feel they don’t have what it takes to get better and simply cannot be helped. I have also seen patients go off on their own and assign themselves extreme things, some of which were potentially hazardous, in an attempt to get well “perfectly.” Another problem is that patients continually obsess about how to do their assignments perfectly, end up procrastinating, and never actually get around to doing anything at all. Their therapist might mistakenly believe that they are simply being uncooperative or are unmotivated, not wanting to face their anxieties.

A high frequency of negative obsessive thoughts

These negative obsessive thoughts typically sound like, “You can’t get well,” “Nothing can help you,” “Even if therapy works for others, it won’t work for you, because you’re the exception,” or “You’re hopeless so you should just give up.” Those who can’t recognize these as being the product of their OCD are certainly not going to feel very motivated or capable, and may even want to quit.  They conclude with the question, “How can someone as hopeless as I am ever recover?”

OCD causing extreme doubt, which then gets in the way of participation in therapy

OCD, as we well know, has been called The Doubting Disease, and one significant doubt it can cause is “Maybe I don’t really have OCD at all.” It can go further to suggest to a sufferer that they are actually “insane” and most likely have another mental health condition, such as schizophrenia, and therefore can never recover. The result can be a whole new round of compulsions, with the patient looking up endless articles on this new disorder in an attempt to try to figure out their true diagnosis. It may also lead them to conclude that they are in the wrong therapy and cause them to lose confidence in their treatment to the point of wanting to drop out.

Doubts can even be more basic, with a sufferer asking themselves, “What if I didn’t do my therapy homework? How do I know I didn’t forget to do it, or that I’ve ever done it at all?” This can lead to endless checking to the point that homework can’t even be approached, or to repeating the same assignments over and over to make sure they were carried out. A different type of uncertainty may cause the sufferer to have doubts about their therapist, asking themselves things like, “How do I know my therapist really knows how to treat OCD?” — our assumption here being that the therapist is indeed qualified — “If they don’t, I could be getting the wrong treatment advice and won’t get well, or will come to harm as a result of misguided therapy assignments.”

A further type of doubt can take the form of a patient worrying about future events connected with their treatment, and might sound like, “What if years from now when I’m doing well, I forget what I learned in treatment, get into a difficult situation, and have a total relapse?” This can lead to such severe worry and obsession about future events that they cannot focus on carrying out treatment in the present. When it comes to taking medication as part of treatment, OCD might not spare that either. Even if a medication is working, it can sometimes tell a sufferer, “How do you know if your medication is working? What if you only think it’s working and it really isn’t?” The sufferer may then stop taking the medication as a way of checking, causing their symptoms to worsen because they aren’t taking it regularly.

Obsessive thoughts actively disrupting Exposure and Response Prevention (ERP) assignments

A good example would be a patient whose obsessions told her that she could not succeed in her college studies because she wouldn’t be able to remember anything she heard in class or read in her textbooks. When she was given exposure homework to confront and even agree with these thoughts in various ways, her obsessions then shifted direction and began to tell her that the therapy homework would never help her because getting admitted to college proved she obviously could remember everything and that she was totally wasting her time in therapy. This led to her not doing the therapy homework, and once she went back to studying, the thoughts quickly reversed themselves and once again told her she wouldn’t retain anything. This vicious cycle clearly did not make for consistent therapy participation.

Taboo intrusive thoughts altering the motivation to continue treatment

In the case of taboo intrusive thoughts (such as those that are sexual and/or violent in nature), there is a particularly disruptive obsession that goes something like, “Maybe all that is holding me back from acting on my violent impulses is my anxiety, and if therapy takes my anxiety away, nothing will prevent me from going insane and killing people.” This results in the sufferer starting to question whether therapy is a good idea after all, and thinking that maybe they would simply be safer staying with their symptoms and not taking any risks.

Superstitions turning homework into a hindrance

Superstitious thinking can also interfere, paradoxically turning normally helpful therapy assignments into compulsions. This can result in homework having to be done in a certain way (e.g., repeated a special number of times, or performed with a particular “good thought” in mind) or, according to the obsession, something bad will magically happen to themselves or others.

As can be seen, there are numerous ways that OCD can potentially undermine the therapy process and stand in the way of a recovery. There are no doubt many more not mentioned in the list above. Many of these intrusive worries may not show up in the first few therapy sessions, only emerging once the actual work of therapy has started.

The question that logically next arises is, how does one prevent this from happening? If you are a therapist, this is a situation where a thorough understanding of OCD and its many different forms is crucial. You have to really listen to your patients and if, for any reason, they do not seem able to come to grips with therapy assignments, you have to go beyond simply assuming they either are lazy, don’t have the motivation to recover, or aren’t on enough medication. Pay close attention to the thoughts and behaviors that precede situations where homework can’t seem to get going, or suddenly starts running into obstacles.

Some possible behavioral assignments to counter these new obstacles might include having the patient:

· Do therapy homework incorrectly or imperfectly on purpose, and then saying that because of this, you won’t get well.

· Carry out assignments an unlucky number of times, and then saying that bad consequences will surely follow.

· Agree with thoughts of not being able to recover or doing badly.

· Affirm ideas of having another mental health condition (such as schizophrenia), being insane, or untreatable.

· Agree with the idea that homework may not have been done at all and that recovery will be impossible.

· Not double-checking whether homework was done, or done correctly.

· Resist having to do homework according to special ritualistic rules beyond those rules indicated by the therapist.

· Going along with the belief that losing the anxiety will definitely result in losing control and subsequent violent behavior, and then doing the therapy assignments in spite of this.

· Telling themselves that the effects of therapy won’t last, that whatever was learned will be forgotten, and that only relapse lies in their future.

· Continuing to take medication as directed, but agreeing that it just isn’t working and will never work.


The point of all the above exercises is to help sufferers build up tolerance to their intrusive thoughts to the point where they no longer have any impact – in other words, applying the basic principles of ERP. I like to tell patients the goal is to ”get bored” with the thoughts, and that they can allow them to simply be there but without having to escape, avoid, or cancel them out in some way. I point out that, by not staying with or confronting their thoughts, they will simply remain sensitized to them and will continue to be negatively influenced by them. This is not easy to do, but it can be done with the right kind of help and support. It takes a lot of persistent work over time, as well as much patience with the usual ups and downs that are normal to any change process.

Last Updated on Wednesday, 12 July 2017 23:39

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