OCD, Language and Navigating Uncertain Forks in the Road

It sometimes surprises people to learn that Obsessive Compulsive Disorder (OCD) is about more than repeated behaviours, hygiene or paying excessive attention to detail and order. Though half the world jokes about being a “little bit OCD” as though it were a badge of tidy pride and organisational perfectionism, the World Health Organisation once listed OCD as being one of the top ten causes of disability.

In truth, at the heart of OCD are very loud, deeply unwanted thoughts with meanings that, to the individual sufferer, feel quite literally unbearable. The weight of these thoughts feels so great that, at some point in our histories, those of us with OCD found ourselves doing something specific in our minds or in the world to push away or “neutralise” a thought. For a few brief moments – maybe only milliseconds – we found this provided some brief relief from the terror and torture of accepting this thought as true, or allowing that we had generated this monstrosity in our own mind.  And so, the next time a troubling thought appeared, we did it again.

Over time, these actions taken in the service of returning us to ease and comfort become more and more of a problem than the initial thought ever was. Our OCD attempts to avoid our own uncertainty and doubt about our thinking and feeling gets us doing things we don’t need to do, just to “feel right” in ways that, at best, take from our ability to be present in our own lives, and at worst, lead to isolation, significant disability and tragic consequences.

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There’s a particularly fine metaphor for how easily we can use our minds to dislocate us from unpleasant internal or external experiences in “A Mouse’s Tale”from Lewis Carroll’s Alice in Wonderland:

"Mine is a long and a sad tale!" said the Mouse, turning to Alice, and sighing.

"It is a long tail, certainly," said Alice, looking down with wonder at the Mouse's tail; "but why do you call it sad?" And she kept on puzzling about it while the Mouse was speaking, so that her idea of the tale was something like this:-

You are not attending!" said the Mouse to Alice, severely. "What are you thinking of?"

"I beg your pardon," said Alice very humbly, "you had got to the fifth bend, I think?"

"I had not!" cried the Mouse sharply and very angrily.

"A knot!" said Alice, always ready to make herself useful, and looking anxiously about her. "Oh, let me help to undo it!"

"I shall do nothing of the sort, said the Mouse, getting up and walking away. "You insult me by talking such nonsense!"

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Most people, if they’re honest, will “get” Alice’s experience here. Who hasn’t been miles away in daydream or fantasy when “listening” to someone telling a long tale in conversation, or faced with an unpleasant task?  We all do it.

Why I particularly like the Mouse’s Tail as a metaphor for OCD, however, is that it articulates key aspects of my own OCD experience. Not only is Alice’s imagining of the tail vivid and visual, but she responds to it as though it were real in a way that makes absolutely no sense to the Mouse. While what Alice imagines is completely coherent (sensible) to her and directs her actions here in ways that insult and annoy her listener, it also takes her away from any awareness of what the Mouse is actually saying. By the time the Mouse notices, Alice, oblivious to the direct experience of the conversation , is entirely locked in the “rules” of her own imagining. Her original intention to be a helpful, collaborative communicator is quickly and completely lost.  

For me, OCD Mind is often a lot like Alice, over-attending to some seemingly random cue, generating a lot of superficially meaningful noise and persisting with listening to it long after it’s helpful to do so, usually annoying myself and everyone around me in the process. All in the service of avoiding a long, sad tale!  

The suffering of OCD: the surprising role of language

How and why might OCD Mind come to work like this?  A contemporary behaviour analytic theory, Relational Frame Theory,  might provide useful clues.  

Relational Frame Theory (RFT) is a complex scientific account of human language and how it shapes our behaviour in context. In RFT, all thoughts are private echoes of our language histories.

Language is a learned ability to relate things, actions, events and ideas in meaningful ways that help us to learn and apply rules to make sense of how the world works.  From infancy, we learn to treat arbitrary strings of sound (words) as real live things in the world, as “true” as the living experience of tasting a lemon or kicking a ball.

A lot of the time, this is very useful indeed: a toddler walks towards the oven and we can shout “hot!”, preventing a nasty burn. Crucially, from very early on in childhood, we don’t need to be directly taught links between words and ideas. We simply derive (or work out) new relationships between experiences without any training or conscious effort.  This is a fundamental basis of our amazing learning abilities as humans.

The relationships we learn between meanings have a strong influence on our behaviour: it changes what we do.

For the majority of people across the world, learning that there is a damhán alla (dah-wAWn olla) on their shoulder isn’t going to provoke much of a reaction.  On learning that this Irish word means “spider”, that situation can change pretty rapidly!   

                 

This example shows that, without even realising it, we constantly use language to relate to new experiences, updating our understanding of how the world works as we grow and age and our environment changes. This is particularly useful, given that aspects of our lives are always changing, often in very unpredictable and surprising ways.  

However, this wondrous magical skill comes with its own shadow. To be useful, using and responding to language needs to happen incredibly quickly, so it isn’t something that can afford to be endlessly effortful. In its drive for efficiency, language pulls our attention in particular ways. From early on in childhood, we learn new information most easily when it coheres (or fits with) things we have already learned.   Over time our “meaning networks” crystallise: the more learning we have about a particular network of related words and ideas, the more coherence they will come to have for us in making sense of our experience.  In other words, the more we relate two or more meanings, the more “true” these relationships will feel, and the more likely it is we will react to them as “true”.

So far, so good – so why is this particularly important for OCD?

OCD is essentially a problem of ideas and learned rules impacting on thinking and behaviour in ways that are so well-rehearsed they are no longer very sensitive to updating through direct experience. While of course a doorknob can carry germs that may bring a risk of illness or cars can injure others, when someone with OCD has washed their hands for the fifteenth time in three minutes or driven the same stretch of road ten times looking for evidence they’ve run someone down because there’s a possibility this might have happened, there’s been a pretty significant severing of meaning and experience.  

Benjamin Schoendorff is a clinical psychologist and author and co-author of several books about Acceptance and Commitment Therapy, a contemporary cognitive and behavioural therapy, including the recent ACT Matrix and ACT Practitioner's Guide to the Science of Compassion. Benjamin suggests that, in OCD, discriminating between perceptual experience and imaginary meanings becomes problematic.The direct experience of checking the stove isn’t as salient or convincing as the meanings mushrooming in the mind of the OCD sufferer.

Relationships between obsessional ideas can quickly come to flood meaning networks, taking over and negating awareness and ability to learn in the moment from direct experience, leading to doubt and confusion about what really happened. As our thoughts travel with us, once the visual cue of the stove is no longer in view, any continued and threatened focus on the derived risks can lead to the person with OCD “living in a bubble” and contacting (and believing) perceptual experience less and less.  Like Alice, we find ourselves stuck in a story that makes sense to us but bears no relationship to what we need or want to be doing at the moment we’re lost in it.

The coherence of meaning around our obsessions can become so powerful that those of us with OCD can feel helpless in the face of it, until thinking and doing other things feels all but impossible. In a vicious cycle, the meaning network of our obsessions demands constant feeding, and every time we respond to its pull and do what it tells us to do, we add to it and strengthen it further, sending us further down the rabbit hole, all the way – in some cases – to the vanishing point.

Of course, while all of this is going on, our mental energy is so trained on the content of our obsessions, we’re increasingly missing out on… everything else. As Matthieu Villatte, a clinical trainer and co-author of Mastering the Clinical Conversation: Language as Intervention, puts it: “I think in OCD, as in many other problems, people fragment their lives and prioritise some stuff over others in ways that creates suffering.” Matthieu says. “OCD can be driven by an excessive focus on negligible risks which in time, negatively impacts many other life areas.”

Changing Language to Change Behaviour

Contemporary cognitive behavioural therapies recognise that the way out of the rabbit hole of OCD involves changing behaviour in ways that move us away from chasing the White Rabbit of our thinking. One way of approaching, this is making deliberate changes to the language we use in relating to problematic thoughts.  

There’s a catch though: this isn’t something we can just decide to do without considerable effort, and as we grow new meaning networks around thoughts and behaviour, we don’t have the option of deleting previous learning – OCD meanings that have been well-rehearsed and learned will linger and continue to pop up and pull on our attention.

If we can't escape language.... what then?

One thing for sure is that simply arguing with OCD thoughts isn’t usually useful. Trying to prove an OCD thought as “true” or “untrue”, “rational” or “irrational” keeps the focus on the meaning networks that are already dominating and dislocating us from our perceptual experience in unhelpful ways, and can even become its own compulsion, as cognitive problem-solving comes to provide its own reassurance about risks.  

If we want to free ourselves from OCD mind dictating our lives, we need to do what seems most paradoxical of all. We need to accept - and have compassion for - our underlying fears that the world makes no sense, and let go of attempting to make things certain. Effective therapies for OCD  involve facing fears that not engaging in compulsions will result in destruction and chaos, and resisting urges and impulses to make everything always "make sense".  

For most of us, Exposure and Response Prevention or ERP(exposing ourselves to our fears without engaging in compulsions) is a core part of this therapy. 

Of course, this terribly scary when, caught in the grip of obsessional belief - our walls closing in around us - we believe that by doing or  not doing something we will cause grave harm to ourselves or those we love.

To help us approach ERP willingly, the most effective therapies for OCD will also help us as sufferers to discriminate between our felt sense that a thought is “dangerous” and what is really happening in our lives: in other words, to develop and elaborate the meaning networks of our obsessions in ways that enable us to shift from an essential coherence, where we really believe our thoughts instrinsically match the way the world works, to  a pragmatic and functional coherence in areas of life that matter to us. 

Tools for Navigating Wonderland: Mindfulness and Compassion

Jon Hershfield and Shala Nicely suggest that those of us with OCD are people "who see, without even trying, the fine print of human experience".  With a propensity to notice and quickly make stories of our thoughts, we can quickly and easily be carried away from the here and now to imaginary, horrifying realms from which we struggle to disengage.

Stepping back from the flow of thought and recognising the distance between our stories about what might happen if we don't engage in compulsions and what is happening right here in this moment a critical skill.  It is also a courageous one when underlying feelings - of terror, or shame, or anger or pain -  bully us into accepting directions from an unrelentingly critical, perfectionist and abusive internal OCD dictator.

To be willing to become increasingly aware that OCD directions are happening in the mind and stay with that, releasing the need to do compulsions to get certainty or reassurance, is an exposure: not an easy way out, not fluffy or light. Even carrying out exposures involves high-level Mindfulness, when we anchor in the trigger and return our attention to what is happening now, rather than engaging in compulsions.  We don't need a formal meditation practice to do this, but it can be a healthy habit to engage in to give us space and time to practice the skill of returning to now, and staying with whatever painful or difficult material arises.

Cognitive Behavioural Tools: Finding a new way of relating to thinking

Fiona Challacombe and Paul Salkovkis's Theory A/Theory B technique is a Cognitive Behavioural Therapy tool which uses questions to enable a person to contact that their obsessive concerns relate to worry rather than actual danger and, rather than wasting time challenging the "truth value" of these, simply discriminating this, then experimenting and exploring how both theories "work" for the person with OCD.  This involves considering in some detail the nature of the problem that OCD "is" in someone's life. What does it mean for this person when they feels compelled to solve this problem? Theory A states the problem as OCD might say  it is. Theory B states the problem as a worry that the world works as OCD says it does.

For example:

Theory A: My problem is that I must wash my hands after touching that doorknob or I will risk certain death

Theory B:  My problem is that I worry that I must wash my hands after touching that doorknob or I will risk certain death. Contamination fears are a psychological response to fears of dying that I can work on

- What is the evidence for both Theory A and Theory B?

- Why do I believe this?

- What do I need to do if this is true?

- What are the implications of buying into this idea?

- What will my life be like if I carry on acting in this way?

Looking at these questions in an experimental, open and curious way helps elaborate the "Theory A" meaning network that drives OCD behaviour, orientating us as sufferers to the causes and costs of obsessions and compulsions - enabling some distance between the person's dominant thoughts and ideas about the way OCD (and the world) work, and fostering additional flexibility when approaching OCD rules.



Acceptance and Values: Changing the Language Game 
From a contextual behavioural framework perspective, Matthieu Villatte explains, it can also be hugely helpful to reframe obsessional and compulsive beliefs and behaviour in order to move willingly towards making consistent change in the face of internal challenges: "We want to contextualise the OCD belief in terms of the person's values (what matters most to them in living a meaningful and vital life) and help to inject some pragmatism (or thinking about what is workable and useful) into the symbolic network. Okay, it's true that there is definitely maybe a risk of dying through contamination if you touch doorknobs, so there is no reason to try to debunk that belief... and.. when you act to avoid contamination, how does that impact your life in general?"

One practical example of how to achieve is use of a behavioural sorting tool such as the ACT Matrix. Based on an original idea by Kevil Polk, the format was co-developed with Mark Webster and Jerold Hambright. It is based on learning to discriminate between direct experiencing with the sense and indirect experiencing in the mind (on the vertical line below) and then sorting behaviour into directions of orientation - towards/away on the horizontal line.  This creates a box of four quadrants which are assigned categories which can be asked in order to explicitly foster noticing and discrimination of internal and external events and tracking of moves towards and away from what a client identifies as being of most importance in their lives:

Opening up to the painful and difficult feelings, thoughts, emotions, memories, sensations and urges that lie behind the obsessional beliefs that distract us from being in our bodies and in the world is a critical part of puncturing the OCD bubble. Benjamin Schoendorff explains: "Discriminating five senses and mental (or imaginary) experience has a central role in freeing oneself from OCD. Learning to discriminate when one comes to the fork in the road so to speak with the left-hand side goes into the world of OCD imaginings might be of help".

Helpfully, this sorting tool doesn't need to be confined to OCD behaviours, but can include a range of discriminations to develop and deepen meaning networks around what matters to the person, allowing us to track the effectiveness and ineffectiveness of all our moves in life towards and away from what is important for us.

This voyage of discovery can help us mindfully observe how these interact with "hooks" of mind and sensation, enabling a platform for exploration and experimentation with new language rules for acting in the world, and opening the door to new patterns of behaviour and a meaningful and vital life.

Further Resources

To learn more about RFT, check out Matthieu Villatte's webpage and publications.

Matthieu also offers trainings for professionals and has co-authored Mastering the Clinical Conversation with Jennifer Villatte and Steven C. Hayes.  There is a facebook page for those interested in using principles from this work for therapists and professionals who help others.


To learn more about the ACT Matrix,
read the excellent Essential Guide to the ACT Matrix co-authored by Kevin Polk, Benjamin Schoendorff, Mark Webster and Fabian Olaz. There is also a facebook page for those interested in using this work to help others.

Jon Hershfield and Shala Nicely's recent book Everyday Mindfulness for OCD: Tips, Tricks and Skills for Living Joyfully must be highly recommended for its endlessly practical and encouraging, enlivening advice.

The Mindfulness Workbook for OCD, a self help book co-authored by Jon Hershfield, Tom Corboy and James Claiborn is also an invaluable tool for addressing OCD with Mindfulness and Acceptance, using skills from Cognitive Behavioural Therapy.

Fiona Challacombe, Victoria Bream Oldfield and Paul Salkovkis co-authored the self-help book Break Free from OCD: Overcoming Obsessive Compulsive Disorder using CBT, with particularly helpful handouts and exercises to understand the "vicious flower" that maintains OCD within the context of each person's life.

The same authors, along with Asmita Palmer, have also recently published Cognitive Therapy for OCD, which has extensive information on all aspects of providing OCD therapy with interesting information on OCD in context and compassion focused approaches.