Question 1

I know that anxiety has been framed as a danger signal "misfiring" - so the response to that seems like it would be feeling safe. Is generating feelings of safety necessary for OCD recovery?

Reid Wilson · Accepted Answer

That's just what OCD wants you to think: "I need to feel safe." Seeking safety plays right into its hands and will keep you stuck. Imagine someone who obsesses about the safety of their house. So one of their rituals is to carefully check the lock on the front door as they leave for work. Yet once they lock the door and turn away, OCD throws doubt into their mind. "I'm not sure I was paying attention just then." In response to that message of doubt, back they go, rechecking the door. Perhaps they end up checking that lock 12 more times until they feel safe enough to leave for work.

Seeking safety regarding your theme will maintain OCD's control over you.

Question 2

How does exposure work?

Reid Wilson · Accepted Answer

I look at exposure a little differently than the traditional exposure and response prevention (ERP) protocol that most specialists follow. Let's continue that example of checking the front door multiple times, seeking safety. Imagine for a moment that this is your issue. What would my version of exposure look like?

First, you will have to decide that your sense of uncertainty has absolutely nothing to do with the door being locked. Nothing! That's just OCD's ploy: to have you focus on the specific. Therefore, seeking security that the door is locked is a terrible strategy. You can never win by focusing on the specific.

Next, decide to do an exposure. For example, if you typically check the door 12 times every morning, perhaps commit to only checking it five times this morning. (A little excessive, of course. But a lot better than 12 times.) After check number five, turn away, walk down the sidewalk, climb into your car and drive to work. How will you feel? Awful! You're scared, uncertain. That's a terrible feeling. But it's precisely the experience you need to have to get stronger. You have to remind yourself of that pretty frequently.

How is this different from ERP? It has to do with your decisions; it has to do with your designated purpose of this practice. You turn away from the door and act as though everything's fine. You operate as if you do not need to think about the door. Your actions should reflect a position that whether the door is locked is irrelevant. Therefore, every time you start thinking, "I'm feeling uncertain about whether the door is locked," you correct yourself: "I'm just feeling uncertain." Why say that? Because this has NOTHING to do with the door! Yes, you're going to get distracted during the day by thoughts about the door. You might have trouble concentrating as you're driving to work or trying to complete your job tasks. That's the cost of going up against OCD, and you need to pay that price.

Some therapists suggest their clients say something like, "Maybe I locked the door; maybe I didn't. I can handle uncertainty." In my opinion, that's the wrong message. Why? Because they are directing their client to continue to think about the specific. This has nothing to do with the specific. I want clients to take this position: "This has nothing to do with the door, so I'm not going to reassure myself about the door. That means I'm going to feel uncertainty, and I can handle that feeling."

Question 3

Do you advocate an approach focusing on changing the underlying belief system involved in OCD (over-responsibility) or exposure plus response prevention?

Reid Wilson · Accepted Answer

My treatment approach is oriented towards self-help skills. I want my clients to understand the dynamics of their relationship with OCD and what is required to change that relationship. I want to put the skills in your hands. Yes, you will be dependent on us clinicians initially because OCD has caused you some great confusion. We should be working as collaboratively and as deliberately as possible to train you to respond to OCD whenever it shows up in your future.

I personify the disorder as a way to help you understand how to win over the disorder. So, imagine OCD as a grand manipulator. First, it uses the magician's trick of redirection, getting you to pay attention to some major threat out in front of you. "Look over there! Danger! You can stop it! You have to stop it! There's nothing more important!" Let's say you suddenly develop fears of contamination and the possibility of causing your children to become seriously ill. Of course, nothing is more critical to parents than protecting their children from serious harm. What kind of parent would want to carelessly cause their children to become seriously ill or even die? What good parent would not act on that fear?
That's what OCD is looking for: to frighten you about a theme that has high value to you. That way, it keeps you hooked. And while you're distracted – while you're investing your attention in managing that threatening drama in front of you – it has the oh-so-clever moves of a pickpocket. It reaches around and steals your wallet. Only it's not taking your wallet. Instead, it grabs your happiness, your concentration, your relationships, your time – it takes it all from you. It does it by stealing your attention—moment by moment.

That's our job: to comprehend that this is a disorder of uncertainty. Think of this as a mental game, and OCD's task is to dominate you. Once it picks a theme that threatens you, it doesn't give you a sense of safety and certainty until you follow its demand to do specific compulsions. OCD's command is, "You must feel certain about this." If you follow OCD's rules, you're going to lose every time. Why? Because you are paying attention to the wrong issue.

OCD doesn't care one bit about the topic of your obsessions. Not one bit. It needs you to feel anxiously uncertain. And then – most importantly – it needs you to try to get rid of that feeling of uncertainty. That's it. OCD may look complicated, but it's not. It needs you to get rid of your feeling of threat, get rid of your doubt, and try to do that immediately. 
Your job? It is to do the exact opposite. First, you have to decide to treat your theme – the topic of your obsessions – as irrelevant noise. You must accomplish this. Because if you keep thinking it's important, you're going to keep obsessing about it. Nobody can handle believing that they have just run someone over or that their negligence is going to burn their house down. But OCD is never about those topics. The disorder needs you to think it is about a specific doubt. Treatment is about handling a generic sense of uncertainty and distress. That's uncomfortable, but you can handle it.

This is where we start. Think of OCD as being like the Wizard of Oz. A specific threat can terrify you. But if you step behind the screen – if you open up the curtain – you see this little old man pulling levers and turning dials. So we are taking on that little guy, not the Wizard that he disguises himself as.

Question 4

Can I cure my OCD without seeing a doctor?

Reid Wilson · Accepted Answer

In treatment within the health field, some of us are guided by a concept called stepped care. Think of a pyramid. The bottom layer of that pyramid is free or inexpensive information provided to patients to orient them regarding how to respond to their condition. In mental health, that would include self-help books, websites and podcasts. A certain percentage of people with a condition will reduce their risks or solve their problems by following those guidelines. (Think: apply sunscreen, wear a hat, cover your arms and legs when out in the sun to reduce the chances of skin cancer.) In mental health, the next step up might be participating in group treatment for your disorder—the next step up: one-on-one treatment with a specialist. Next might be the addition of medications. Above that is Intensive outpatient treatment and then residential treatment. Perhaps at the top are some of the newer, more experimental treatments, such as transcranial magnetic stimulation.

Stay diligent in your effort to overcome this disorder. Educate yourself. There are lots of self-help books, websites, and podcasts to choose from. However, be careful that you don't search through so many resources that you stay confused. Instead, find a protocol that seems best suited to you and start your work. You may or may not get all you need through your self-help efforts. The most important issue is to stay determined to get the help you need, whatever it takes.

Question 5

I feel like I say all the wrong things to myself when I’m trying to work on my OCD. What should I be telling myself?

Reid Wilson · Accepted Answer

In the answers above, I've given you a few examples of what you might say. Self-talk is critically important to the work I do, and often I think of them as verbal cues; they remind me of the positions you want to take regarding your relationship with OCD. But, first, you need to know that you are not speaking within a vacuum; you are competing against the pre-existing self-talk that stems from your OCD – all the self-talk that allows the disorder to dominate you.

Think about this as a moment-by-encounter with your obsessions or your urges to do your compulsions. Your self-talk can give you support and instructions for four critical tasks in that endeavor:
1.	to spark your motivation and determination
2.	to step back and notice that you're obsessing 
3.	to turn your back on the obsession or the urge to ritualize, and
4.	to redirect your attention to something else

You need to have an aggressive stance against the disorder; you need to go after it. Step forward, right into the fire. Think of this message to OCD: "If I have to take what you're dishing out, then give me two servings, and give them to me now!" OCD depends on you not wanting to be scared, not wanting to be uncertain. Therefore, regarding motivation and determination, your verbal cues should be exactly the opposite: "I want to be uncertain." What else might you say?
•	"I want my life back!"
•	"I'm coming after you, OCD."
•	"This is a good opportunity to practice"
•	"Be scared and do it anyway."
•	"I can handle this confusion [discomfort, fear]."

You can't change any pattern if you don't recognize it. You need to learn how to step back in the moment and recognize that you are obsessing. Stepping back is the first step towards change in the relationship. What you say can be pretty simple:
•	"There's my obsession."
•	"I'm worrying again."
•	"I'm focusing on my theme again."
•	"Whoops, I'm doing it."

Then don't start arguing with that fearful or threatening voice. Your job is to turn your back on your theme – to treat it as noise, as nothing. You can use a simple reminder:
•	"Not going there." 
•	"I'm turning my back on that."
•	"None of my business."
•	"I'm treating this as nothing."
•	"And… I'm out of here."
•	"Let go and let God."
•	"Don't figure it out."
But, don't forget: then you have to do what you say!

If you're going to turn your back on your theme, you next have to turn your attention to what you want to pay attention to. In many ways, it doesn't matter what you turn your attention to. You have to make something else more important in the moment than the obsession or urge. Don't worry about whether the obsession or urge pops right back up again. You've just won this moment, and now you encounter the next one. The work is moment-by-moment.
•	"I'm getting back to work." 
•	"Leave the room now!"
•	"Now, where was I?"
•	"Keep moving. Keep moving."
•	"My job is to push forward."

This, by the way, is what I perceive as the true form of exposure. When you turn your attention away from your obsession or your urge to do your compulsion, the part of you that is victim to the disorder will be saying, in essence, "Where are you going? We've not answered this question! We have to fix this!" You are turning away from an unanswered question. That will provoke, at least momentarily, distressing uncertainty. That's exposure to what OCD is truly about. It's not about your topic! When you get off your topic, even momentarily, you have an opportunity to strengthen your ability to tolerate what you actually need to tolerate, which is the distress of a generic sense of uncertainty. Stop letting your theme distract you from your work.

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