Existential Therapy for OCD

In my work I am concerned with the use that can be made of suffering, alongside the attempt to diminish it. Today I specifically discuss the use a person can make of their mental illness. I focus on Obsessive Compulsive Disorder (OCD). I have supported people in this way while they also undertook specialist psychological treatment for the disorder.
If a person cannot change a hateful truth then what else might they do, insofar as they can do something? They might simply distract themselves from it. Or they might engage in the fantasy ofcontrolling it. OCD performs these functions of avoidance and fantasised control. In a discussion of death-anxiety, existential therapist Irvin Yalom writes about this avoidant and controlling function: “[Research] reports that over 70 percent of patients with a severe obsessional neurosis [OCD] had, at the onset of illness, a security-disturbing death experience. As the syndrome develops, patients are increasingly concerned about controlling their world and preventing the unexpected or accidental. Patients shun disorder or uncleanliness and develop rituals to ward off evil and danger. Erwin Strauss notes that the obsessional patient's disgust at decay, illness, germs, and dirt was intimately related to fear of personal annihilation.” Many people who suffer OCD fail to recognise that they are anxious, or that there is a connection between 1) their anxiety, 2) its existential roots such as the fear of death, and 3) their OCD. All they can see are the OCD “symptoms” which baffle them.

OCD is avoidance. It is magical thinking. It is an attempt to control the uncontrollable. As Yalom suggests it functions (at least in part) as a set of rituals to ward off danger and the associated anxiety. From the outside it is easy to assume that people with OCD are irrational compared to the rest of us, but that is untrue. People with OCD vary in intelligence and sanity to the same degree as the rest of the population. Indeed a part of what pains many OCD sufferers is their sense of the irrationality of their compulsions and obsessions. They do not reflectively believe that they are warding off danger, rather they experience OCD as an overwhelming compulsion linked to what they consider an irrational fear. This is why OCD can feel so humiliating.

But here's the thing. Everybody has a tendency for magical thinking, regardless of how rational and scientific they otherwise are. Once upon a time when faced with life’s dangers we would make a magic potion - perhaps a combination of three herbs - to ward off threats. Our brains are very slow to evolve and this magical urge has not gone away. The potions which people concoct these days use different herbs: instead of rosemary, sage and thyme, people mix together a spouse, career, and mortgage; or cynicism, detachment, and criticism; or some other concoction. The magical ingredients may be fine things in themselves or not. Neoliberalism is a striking example of the latter: “If I am a hard worker then I will do well, I will be safe, and in order to believe this I will also believe that people who have not done well must be lazy or bad.” Or to take a left-wing version, "If I do what is considered compassionate then I will be valued and treated well in life." We all engage in magical thinking, each in our own way. Because many people’s favoured potions are socially-approved - consider the mortgage example above - therefore neither they nor others notice their magical thinking. OCD on the other hand gets noticed. It stands out and is disapproved of, therefore it is seen as a problem requiring pathological explanation even while socially lauded forms of magical thinking are praised.

I am building a picture of OCD as a particular example of a universal problem. The universal problem is that we all suffer anxiety, which occurs in the face of our human vulnerability, and we all find ways of avoiding it and warding it off. With respect to particular ways of achieving this universal tendency different people engage in particular - non-universal - strategies. For example some people give over to conventionality, some become bitter, some greedy, some depressed, some obsessive-compulsive. Every person has an arsenal of particular strategies, which differ from their neighbour’s methods, for engaging in the universal act of avoiding anxiety. I will unpack this some more.

I noted before that Yalom suggests that OCD functions, at least in part, as a set of rituals to ward off the danger which evokes anxiety. There are three elements here: the obsessions or compulsions (OCD), the danger, and the anxiety. The existential picture of OCD which I have painted is structured around these three elements, and if we set them out in order we can say that each is a response to the one below it:

1.  OCD is an avoidance and control of

2.  anxiety, and anxiety is a response to

3.  the vulnerability (danger) of our human condition.

Through avoidance and magical thinking OCD is an attempt to be ignorant of, and to control, the anxiety we experience, in response to the danger we face as human beings in the form of the vulnerability of the human condition. From the existential viewpoint that I am setting out, this is how OCD arises in a person.

To picture the three steps another way, if we were to peel an onion, so to speak, the structure of OCD might look like this:

There are various psychological ways of responding therapeutically to OCD. The most common approach takes a medical, cognitive-behavioural, and often neuroscientific, approach. This is captured in Jeffrey Schwartz's Brain Lock. There are also psychodynamic/psychoanalytic approaches, and Nancy McWilliams' Psychoanalytic Diagnosis exemplifies this, while a more detailed discussion can be found in H.P. Laughlin's 1967 book The Neuroses. The essence of existential therapeutic support for OCD is that we need to come to terms with life. The challenge is to face reality and accept it. And by acceptance I mean, ultimately, that we need to learn to love life. To love this life with full emotional recognition of the painful truths from which we instinctively withdraw.

Readers who are waiting for something more clever, a technical intervention, a psychological strategy, might assume that the above is a first step. But as Kierkegaard said, “Whoever has learned to be anxious in the right way has learned the ultimate.” This recognition and acceptance of reality is itself the greatest challenge in life, and its achievement is harder than we realise. Strategies fall by the wayside by comparison.

This is not a matter of heroics, but it does require courage. Many who suffer OCD are particularly sensitive to the painful truths of the human condition, so they may need more courage on a day to day basis than those with a talent for blindness. The way forward is demanding, but it is worth it. My concern with the medical model, which reduces OCD to a meaningless mental illness, is that unless we struggle with the valleys and peaks of our inner life, then we become passive. We need to be active, to be agents in our lives. We cannot hand over our recognition of, and struggle with, the human condition to technical experts who will 'treat us'. It is an abdication of the self to forgo both attention to one's inner life and the need to craft it. To forgo is to reduce oneself to an object, to being inauthentic in the existential sense - failing to author one's life. It is the land of the mechanical, the functional. In Kierkegaard's words, we have then lost "the ultimate." This is why van Deurzen writes that "anxiety should be the starting point of therapy, not in order to alleviate it, but rather because anxiety must be considered the starting point of a well-lived life."

Just as OCD is a particular expression of a universal challenge, so too it can be a particularinvitation, and means, for facing the anxiety of the human condition. We need to find a use for OCD rather than simply a cure. To use Kierkegaard’s wonderful word again, we have realised “the ultimate” when both pleasure and suffering are secondary to the pursuit of genuinely good living. Of course this runs counter to our tendency to believe that pleasure equals good and pain equals bad, that pain is something with a negative value only which must be done away with. If you suffer OCD then, as strange as this sounds, although you suffer, you may be more fortunate than the person who engages in evasion and magical control through pleasurable or socially-approved means. For in your case you cannot fly under the radar, you are confronted with your behaviour, confronted with “the starting point of a well-lived life” (van Deurzen). Normal forms of evasion and magic do not involve the pain, and neither do they attract the sort of criticism, which invites change. OCD can be a pathway, for becoming more attentive to life in its depths, including its universal vulnerabilities and the pain attached, and more courage and loving.

I am not saying that you shouldn't try to diminish your OCD, but rather that you might also take this different attitude, holding on to your desire for a cure while also putting your problem to a higher use. Perhaps this approach will make more sense to those who have tried to cure OCD by conventional means and found that it does not go away so easily. Of course the distinction between a cure and a use fades in reality. OCD is something that you do, and to use OCD in this way is to do the opposite of OCD: facing the fear rather than avoiding it, courageously loving life with all its danger. Therefore this use weakens the obsessions and compulsions at their root. However to maintain the important distinction, such a cure is not my main point. Indeed, such a paradoxical ‘cure’ only works if one values the use of OCD above the desire to cure it. This requires that one accept that they may always have a tendency to OCD as their instinctive strategy for reacting to life’s anxieties. This does not mean they cannot largely overcome it. How do I know? I grew up with pronounced OCD and I took this approach to it. Nobody would guess that OCD sits in the back of my mind like a subtle white noise, for I no longer act of the compulsions. I faced them in the way I have described.  

So I am suggesting something more daring than an alternative cure for OCD. I am saying that one ought to consider consenting to the existence in your life of OCD, and doing so in each moment, as a consent to, or perhaps lucidity about, that which it avoids. What it avoids is no less than our humanity, the human condition, which is a dangerous situation. To consent to this reality is a work of wisdom and love.

I have set out a proposal to treat OCD as a means, on reflection not unlike those spiritual exercises which ancient Stoic philosophers and medieval monks engaged in, to grow in lucidity regarding our human condition. To grow in your capacity to bear well the anxiety which courageous living arouses. And to hone a capacity to love life. I welcome your comments and questions.​
 


Author: Matthew Bishop
Art work: Michael Kerbow