Breaking Down Obsessive-Compulsive Disorder: The Heart of the OCD

• The Legacy of OCD
• Sound and Fury
• Meaning Matters

The Legacy of OCD

When I was in third grade, I was gripped by the fear that my mother would be killed if I didn’t follow orders. From whom and where these orders were coming wasn’t entirely clear, but I quickly learned to obey. Like the main character, John Nash, in the movie, A Beautiful Mind, I was being watched, and everything I thought was monitored for loyalty to the sinister totalitarian state of which I had now become a new citizen. There was no way out.

Every day at the religious school I attended, it whispered in my ear, “She’ll be dead when you arrive home if you think something bad.”

Living each day with a pure heart became a new curse it threw in my face, a way to trap and punish me in the most painful way imaginable. It would take away the person I loved and needed most in the world: the single mother who protected me and the flame of sensitivity within me which the world seemed all too eager to snuff out.  

When the neighborhood kids dared me to throw away my Winnie the Pooh bear all too soon, I foolishly gave in and was heartbroken. The next night, Paddington Bear in his blue duffle coat and red bucket hat appeared on my bed. When we returned from the movies, my mother asked about the hopes and fears of the characters because she could see it still percolating in me. Like a music conductor, she’d encourage me to allow every section of the orchestra of my mind and heart to play out just a little louder, strengthening a confidence in an invisible capacity I could not yet name.

I adored my mother and knew that without her, my sensitivity would be swept away. So, as Abraham did with God in the story of Sodom and Gomorrah, I negotiated with the amorphous all-powerful entity controlling my fate. If I read every word in the prayer book, it might be appeased. If I had an evil thought, I could cancel it out, and if done right, the entity might be mollified, but in the end, the charges kept returning. No sooner was I absolved of a crime I didn’t know I committed when a new trial restarted. The world was full of impossible binds. Death and doubt resurfaced at every turn.

It wasn’t surprising that I developed OCD. My mother had an identical fear of losing her mother at the same age and struggled with contamination OCD, opening doors with tissues and ever ready with rubbing alcohol. “It’s just my craziness,” she’d confess.

One day, a red futon tied to the roof of our car fell while driving along the highway. Pulling over to the side of the road, 10-year-old me peered into my mother’s eyes expecting to find terror there.  

“This stuff, Michael, the big stuff doesn’t scare me. It’s the little things that get me, remember?”

And with a smile, I helped reattach our precious cargo.

My mother was familiar with living an existence as paper-thin as the tissues she carried with her everywhere to ward off germs. Her parents’ marriage fell apart shortly after their arrival in New York from the Middle East via Panama, when her mom — my grandmother — became the main breadwinner and caretaker of the family of four young children. Sensing her fragility, my mother stepped in to minister to her. A highly educated woman now working behind the counter at a department store to make ends meet, and my mother easily noticed the pain — the unspoken sadness, longing, and fear that others hardly detected. Even my mother’s siblings mistook their mother’s desire to have joyful holiday dinners as just another form of control, instead of what it really was: a cry for help. Please eat and show me, not only that you love me, but that somehow God hasn’t abandoned me like my husband. 

My mother stayed close to home, learning to fear rather than crave independence. Without the freedom to disagree or feel anger, her sensitivity became the emotional suture for a constantly bleeding family. In doing so, she lost much of the thread holding herself together. She doubted her own instincts and confidence, even though she had a sixth sense of empathy few recognized as her hidden superpower. English professors noticed it and called on her regularly for her insights in class, but in the real world, she felt unmoored.

OCD emerged as an expression of how precarious the world felt to her. It offered her a blameless way of seeking the boundaries and guidance she couldn’t ask for directly. When OCD dictates something — when it says, “please tell me everything is going to be okay, please wash your hands, please help me right now!” — it allows for an aggressive urgency that’s otherwise forbidden.  

Sound and Fury

As a psychologist, I’ve treated individuals struggling with OCD since my graduate school days. Then, you could find me on the streets of Manhattan touching tissues to doors and diluting them before doing exposure exercises with clients. You’d find me in the library turning over every stone in my dissertation research on what did and didn’t work for OCD.

These days, I get calls and emails from clients around the world who fail OCD treatment and say they’re not encouraged to talk — even with their own therapists — about the deep feeling and fire they experience within their OCD. To attribute any meaning to OCD, they’ve been taught, is to enable reassurance. To envision OCD as anything other than a bio-behavioral glitch is dangerous and foolish. “It takes seventeen years on average to arrive at appropriate OCD treatment, why would you jeopardize that,” say their therapists. But what if, instead, we listened to what burns so brightly inside OCD?

My perspective on OCD is likely to be dismissed as misguided and anachronistic, even taboo. In the OCD community, talk therapy is believed to be unhelpful at best and regressive at worst. A widely circulating meme in the recovery world echoes the mainstream view, inspired from a passage in Macbeth: OCD is “just sound and fury, signifying nothing.” But what if the meaning at the heart of OCD is there and we’re just not talking about it? What if these clients aren’t failing treatment but treatment is failing them?   

OCD is as much about feeling as it is about thought, as much about meaningful self-expression as distracting noise. Hardwired by nature and stoked by nurture, our brains repeatedly throw an unsolvable dilemma that’s trying to communicate something valuable. OCD is both friend and enemy, but we tend to view it only as an enemy because by the time people get help for it, it’s a five-alarm fire. If you look at it with the right eyes — ones attuned to the sparks of sensitivity within it — you see raw potential in it that’s inspiring, sensible, and bold.

I’ve long been one of the few therapists who espouses this unpopular view. When I questioned CBT orthodoxy in training and experimented with integrating meaning-centered approaches, I was asked to turn in my badge. When I suggested that OCD had an upside in a recent Christmas blog — and foolishly called it a superpower — I was as welcome as the Grinch. Recently, though, I’ve been heartened by two exciting developments: Internal Family Systems as a new OCD treatment and John Green’s book, Turtles All the Way Down, an OCD-inspired story recently made into a movie by the same name.   

Meaning Matters

Internal Family Systems is an evidence-based therapy that helps sufferers befriend their OCD protectors. These parts nurture the sides of the self that have been cut off due to trauma like my mother’s or the intergenerational trauma I inherited. The overactive OCD mind perpetually anticipates dangers and buffers feelings of rejection, hurt, sadness, and terror. If these managers don’t succeed, firefighters take over with compulsions. Running the gamut from checking, washing, counting, or reassurance, compulsions provide visceral instant gratification. They comfort with a cost; repetition is the only way to satisfy, though not for long. Any satisfaction you achieve doesn’t last, and it’s never enough.

My mother’s compulsions to wash her hands were frequently triggered after being recruited into carrying too much of other’s emotional mess. With no relationship to help verbalize her profound empathy and disgust for being placed in such an impossible role, her protectors took over. My own terrors were touched off by the adult world coming for my bear again, only this time it replaced the bear with my mother. I’ve worked with clients whose OCD took away their freedom to sing, to take the subway, or to trust their own goodness. Each of them found unexpected ways to link their OCD to a fuller, more coherent story.

In Green’s book, one of the characters questions a scientist who has given a detailed history of earth and life on it. She insists that the entire world is resting on the back of a giant turtle. When he challenges her about what that turtle is standing on, she replies “it’s on another.” Flummoxed about what that turtle is standing on, she replies, “Sir, you don’t understand. It’s turtles all the way down.” This image doesn’t just capture the repetitive and elusive nature of OCD, it speaks to a hopeful afterimage. What if everything you think of as the random chaos of OCD is held up in more creative ways than you ever imagined?

In recovery from OCD himself, Green crafted Turtles All the Way Down to showcase OCD’s characteristic thought spirals and the methodically masterful ways it wears down its main inhabitants and robs them of their agency. OCD is a nuisance to be rid of, not exalted. As an OCD advocate, Green wants us to feel that. And yet, his characters tell another story, centering OCD around its existential heart, a profound sensitivity hardly ever discussed. 

Teenage protagonist Aza Holmes is haunted by the sudden death of her father from a heart attack and OCD jumps in to protect her — IFS style — from overwhelming fears over the precariousness of life. Is Aza really just a fictional character without any volition of her own? Is the 50 percent of the bacterial microbiome that makes up the human body in true control of her? Aza constantly digs her thumbnail into her middle finger to see if she really exists. But no sooner than she is found, she is lost again, spiraling about the possible infection she’s now unleashed.

Aza’s OCD finds an ingenious way of expressing her existential dilemma. Her scab is a brilliant metaphor of the ever-present wound of her father’s death and all of our deaths. Like my own childhood terrors, the relentless question — to be or not be — constantly buzzes in the OCD sufferer’s ear, a fly always just out of reach. As for Hamlet, a broken heart — not a worried mind — is at the center of OCD. Or as Aza puts it: “When you lose someone, you realize you’ll lose everyone. And once you know, you can never forget it.” A broken heart — not a worried mind — is at the center of OCD.

***

It’s been more than 15 years since my worst nightmare came true and I lost my mother to cancer. And yet, in the aftermath, something shocked me in ways my early fears never prepared me for: instead of falling to pieces, I discovered something new in conversations with my mother in my dreams.

I finally get what you meant that day on the side of the highway. Like those turtles, you were carrying the world on your back. The big stuff. You saw that I could do it too and protected that power every step of the way. You knew how to celebrate it as a gift never to be taken or lost. I realized that gift was life itself, and it was the mysterious heart of OCD. It was holding me up better than any of those turtles ever could, and with it, I could carry everything.

Questions for Thought and Discussion

What methods have you found to be most effective in addressing OCD with your clients?

How have you used metaphors in the treatment of OCD?

What do you find to be the greatest challenge in working with OCD?  

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