Mapping the Heart Of OCD: Going Beyond the Conditions We Know

• Capitalizing on Empathy in OCD Treatment
• Kate’s Therapeutic Journey

“The heart has its reasons of which reason knows nothing.” —Blaise Pascal

Capitalizing on Empathy in OCD Treatment

Some diagnoses are no-brainers when it comes to treatment. Poll any therapist with a pulse and ask them what’s the best intervention for OCD, and you’ll get the same answer: Exposure Response Prevention (ERP).

ERP is a cognitive-behavioral technique whereby OCD sufferers stare down their biggest fears and learn not to blink. Intending to conjure up their personal worst-case scenarios — the terror of harming a newborn child, the yuck factor of hands submerged in an overflowing trash can in Times Square, or entertaining the possibility that they just might be a psychopath — ERP performs an unusual sleight of hand. By leaning into rather than avoiding anxiety, sufferers break OCD’s unruly spell.

Although highly effective at providing relief for symptoms, ERP is a mind and behavior-oriented approach that misses the most astounding feature of the OCD tribe: their enormous hearts. People with OCD are amongst the kindest and loveliest clients with whom I’ve worked.  

And it’s not just my own bias, research confirms this big heart. Recent studies found that individuals with OCD show higher empathy levels compared to healthy controls. They shared the suffering of others in both self-reports and in a naturalistic task designed to test empathy in real time. They also reported more distress over their heightened empathy and are more emotionally responsive and attuned to others compared to healthy controls.

Such responsiveness is at the core of what makes therapists so effective, and yet for those with OCD, it misses two crucial pieces: the self-compassion and self-advocacy to counterbalance a weighted-down heart. Therapist burnout shows it’s possible to be too empathic, but have we ever looked at OCD from this perspective? Maybe we should!

A behavioral approach gives little room to map this expansive OCD heart, and it’s a real turnoff. Like the Grinch, many OCD sufferers don’t want to touch ERP with a 39-and-a-half-foot pole. Between one quarter and one half of people with OCD decline ERP, in some cases even before it begins.

I regularly take on the challenge of asking myself as a therapist: what more can I learn about this condition by entertaining something completely different? In the spirit of punk rock, what can I glean if I rebelliously take on the mainstream? With its one gold standard treatment, OCD begs the question: isn’t there more we can do to help OCD sufferers find their voice? Perhaps ERP is so popular that few have the audacity to question it. Maybe, as Pascal instructs, the heart has its own reasons. Such was what I learned with and through Kate.

Kate’s Therapeutic Journey

“I almost cried when I read your blog post,” Kate confessed during our first zoom meeting. A cinematographer based in LA, Kate was fast losing hope that she’d ever get past severe OCD that only relented, ironically, when she was on set. “I always thought that I was failing at OCD treatment, not doing it right. Like, why aren’t I strong enough to just sit through the anxiety? But when I read your work, I felt like treatment was failing me.”

Kate read my unconventional theory that OCD arises from an empathic and existential sensitivity that goes unnoticed and unsupported, and turns in on itself. That enlarged heart capable of so much love is also keenly aware of the chasm of loss set before us all. Is it any wonder that the majority of OCD sufferers worry that death might befall themselves or someone they love? Or that the ritual du jour might somehow stave off what we all wish to control? At its root, OCD is a keen awareness of the fragility of life and the myriad spells and incantations we use to hold on to it at all costs, even if we must lose ourselves first.

“My parents and siblings used to poke fun when I was little when I wasn’t ready to let go of my teddy bear like they all did when younger. I carried her everywhere; she was the sensitive heart nowhere to be found in my house. I hated that I couldn’t let her go, and even until recently, I felt that way about my OCD treatment. Why couldn’t I be fiercer and face my fears and just grow up? Why can’t I even do this ERP thing right?”

Kate felt guilty in therapy, too. She admired the OCD specialist who first gave her a diagnosis and regaled her with the promise of ERP. Finally, there was hope that OCD didn’t have to rule her world. If he had saved her — as she so often felt — why wasn’t she more appreciative?

As we talked together, it became clearer: feeling wasn’t on his radar. Her therapist didn’t listen or seem to care about all that sensitivity, and she felt rejected yet again alongside her teddy bear. “What does it matter what your obsessions mean?” he’d shoot back, as if to say, “get with the program, this approach isn’t going to get you anywhere.”

In conventional OCD treatment, obsessions are just noise in the system trying to distract from the most significant mission: full acceptance of uncertainty and ambiguity. While Kate always wanted to make meaning and find ever more intricate forms for her feelings, her therapist just wished she’d keep working hard and be satisfied with her progress. There was little room for her own authoritative and unique voice, all that good fire in her heart.

Kate could also detect something unspoken in her therapist’s heart: how much his identity seemed tied to one singular truth and how it rattled him to entertain otherwise. She vaguely knew something about herself — how she existed in the world — hurt him. But she never put those feelings into words. Instead, they metastasized into self-doubt, self-recrimination, and shame.

It clocked Kate in the face when she recognized her therapist’s philosophy in a meme widely circulating and praised on Instagram in the OCD recovery world: “OCD is just sound and fury, signifying nothing.” Borrowed from Macbeth’s famous line when the walls are closing in on his murderous exploits and he learns of his wife’s death (ironically, Lady Macbeth with her “out-damned spot!” is one of the most famous contamination OCD cases in literature), Macbeth’s phrase is one of horror, lamentation, and hopelessness. The world is a meaningless, obsessional march of tomorrow and tomorrow and tomorrow, a tale told by an idiot.

“What is wrong with me?” Kate wondered. “I’ve always been a failure in treatment just as in life.”

The middle daughter of a highly educated and successful family of Chinese immigrants to California, Kate constantly found herself on the outside. Family members pegged her as unable to let things go, and though they’d never outright say it, weak for not being able to be more driven and hardworking like the rest of the clan. “Even your work is all just fantasy,” her mother complained.

Kate’s sister had already long moved out of the parents’ house at 25 and was now in medical school, setting sights on buying her first home. Her brother, an IT specialist, always seemed to be able to fix just about anything. Kate was the anomaly, still living at home with her parents and never quite fitting into the alpha-driven landscape of her family’s California dreams.

“Why couldn’t she just enjoy the promise of all that beautiful California sunshine?” her father protested. Kate was always adrift in the riptides of her obsessions, what if she forgot the stove was on, burned the house down, and killed everybody’s nascent dreams along with it?

“It’s like I can never do what the mainstream wishes for me. Maybe that’s why I’ve gravitated to indie films so much. It’s my only refuge.”

“I’d reverse that. The mainstream has never really witnessed your profound heart. You have always tried to accommodate the mainstream — your family, your therapist, the world — but it has come at the price of who you really are. Your sensitivity has always been a part of what has made your vision so clear and full. It’s no accident that your OCD largely vanishes when your sensitivity is prized, as it is when you are working on films and the director gives you the go ahead to command what you need to get the right shot.”

Kate always had a whimsical and keenly observant view of the world, and it showed in her cinematography. She always knew which way to angle the camera not just to get the right light or best composition, but somehow, she evoked things out of objects and people that were somehow right there, but beyond them as well. Her prodigious talent landed her on projects that she most dreamed of; it was also one of the few places where she felt free from obsessional doubt.

“Because your parents didn’t see your sensitivity as a gift, it got housed in your own mind, and you had to protect yourself and them from its power. You sensed so much of what was happening in your environment but there wasn’t a place to communicate that. It becomes wild in our own minds, but we need relationships — and art — to tame it.”

Kate is in Good Company

Together, we joked about how many artists and innovators shared OCD and this unique sensitivity, if you were lucky, found a place to give it creative form. How Greta Thunberg, herself an OCD sufferer, marshals her profound sensitivity to the neglect of an entire planet into fierce advocacy to save us all from extinction. How young adult author and OCD sufferer John Green chronicles teenagers staring down their own cancer diagnosis in The Fault in Our Stars and writes of Aza Holmes, the greatest young adult character with OCD in American literature, in his novel Turtles All the Way Down.

Like Kate, Aza seeks her own center. Is she 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 control of her? Aza constantly digs her thumbnail into her middle finger to see if she really exists. But no sooner has she found herself than she is lost again, spiraling about the possible infection she now has unleashed. Compelled to drain the pus and blood, Aza is a hostage of her own self-enclosed system of fear, love, and unboundedness.

The heart figures prominently in Aza’s story too. Her father, also a sensitive soul and unrepentant worrywart, mysteriously drops dead of heart attack while mowing the front yard lawn. Just as Kate is so aware of killing everybody’s dreams and truths in her life, Aza shares a moment of clarity with her boyfriend about the root of her OCD: “When you lose someone, you realize you’ll lose everyone. And once you know, you can never forget it.”

“OCD is a sensibility of sensitivity, one that has an exquisite flame for creative possibility but when traumatically misunderstood and misdirected, it burns the house to the ground. If Gabor Mate specialized in OCD (Kate was a huge fan of this rock-star sage) he’d appreciate it with us too. OCD is more than just a biological glitch; nature and nurture are always in conversation, whether we choose to listen. OCD is trying to tell us more than even therapists are ready to hear. There’s interesting music in all that noise.”

Kate was accustomed to having her true interests and concerns fall on deaf ears. Her relationship with this therapist and with cognitive-behavioral therapy itself echoed her ambivalent relationship to her parents: while she was grateful for having been raised and financially supported by them, they minimized her interests as foolish and viewed her obsessions as just more evidence of her immaturity and self-absorption. Without a clear and secure sense of support from these relationships — her parents or her therapist — Kate relied on her own thoughts and rituals to hold her up.

And yet here was the rub! Untempered by any human relationship, these thoughts quickly became savage and cruel, expecting her to be able to live up to what her perfectionistic imagination could dream up: a world of all-or-nothing purity.

Kate suffered from paralyzing obsessions when out in public places, fearful that the looks of others somehow might cause her to implode. Triggered on subways, Kate left the NY film scene for California where she had more freedom to drive solo. But Kate never quite understood why her obsessions centered around this particular theme and not something else.

“It doesn’t really matter,” her old therapist used to say. That’s the trap of it. It wants you to give it attention and believe it has meaning so you’ll keep on going down the rabbit hole. It’s not to be trusted as your friend.”

But Kate, ever-so-fascinated by the motivations of the characters she tracked in the movies she made, knew there must be more. Obsessions had a funny way of both distracting and focusing us on the things we most feared and desired for a reason. Kafka’s Gregor Samsa didn’t turn into a bug just because he had some tic of the mind, but rather because he felt the alienation, oppression, and depersonalization of his family life and modern society combined.

Successfully Addressing the Heart of Kate’s OCD

We worked on a new kind of exposure response prevention, one that dialed down into all of her feelings and associations with her obsessional fear. As we did, Kate became a more sharply drawn character: she was terrified of being intruded upon, judged, and taken over by the needs of others around her. With her big heart, she was so tuned into the unexpressed fears and desires of everyone that there wasn’t enough room for herself. She sensed the fatigue in her parents, their loneliness for their home country, and their overcompensated worries about surviving. They had no idea that internally she was feeling for them, unconsciously trying to imagine every way she could help them control their fate.

She was compelled to avoid any places which might afford too much scrutiny — subways, planes, trains, long car rides— and wisely found the safest place to exist with complete freedom: behind the camera. There, she no longer was the stage for all the unexpressed feelings of others; she could now orchestrate them for her own artistic purposes.

I knew Kate was making progress in our treatment one day when she started our session rather abruptly, “I know you might want to talk more about what we only half-completed last week, but I don’t want to do that. This is what I need today.”

My heart swelled. I loved the grit, fire, and healthy aggression that I knew she needed to have to own herself, even if she risked temporarily losing me. When I expressed this, she was a bit dumbfounded, “You mean, it’s okay for me to ask this? I’m not screwing up your plan?”

“Kate, it’s always puzzled me why Aza Holmes needed to pick at her finger, but only now do I get it. It wasn’t just any finger; it was Aza’s middle finger. She needed to say a healthy ‘fuck you!’ to the people she loved — her mother, her best friend, even her own OCD — and trust that she was entitled to it. That’s what you’re doing now, and I love it.”

For the first time, Kate began seeing something strong and interesting inside her OCD, like the amethyst crystals spied inside a rock kicked to the side of the trail. She wasn’t broken inside, after all. New facets that other treatments said didn’t exist came into view.

Together, we found the heart of it, the mystery that constantly hovers somewhere between life and death, love and hate, and disaster and possibility. Like Aza Holmes, who had lost her father, her boyfriend, and her beloved Toyota Corolla Harold, Kate recognized the biggest truth of all: “To be alive is to be missing.” And yet, it’s in that unexpected place where Kate was found again.   

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