Why talk therapy can make OCD worse

Key takeaways

• Fear activates the brain’s fight, flight, or freeze response, which shuts down deliberate reasoning so the body can react quickly to danger.
• The fight, flight, or freeze response is activated during OCD episodes, and because executive reasoning goes offline, the brain has trouble distinguishing between real and imagined danger.
• Talk therapy can intensify OCD because the brain interprets talking about obsessions as evidence that the thoughts have relevance and meaning.
• Because executive reasoning is limited during OCD episode, ERP focuses on changing behavior rather than thoughts.

Estimated reading time: 5 minutes

“…I was pouring buckets of liquid on a blazing fire and wondering why it wouldn’t go out. In fact, the liquid seemed to fuel the flames more, as they encircled me, licking greedily around my ankles and trapping me in their fiery hell.

Unbeknownst to me, therapy had not filled my buckets with water.

Instead, it had filled them with gasoline.”

Is Fred in the Refrigerator?: Taming OCD and Reclaiming My Life (p. 114).

Let’s talk about fear.

Say you’re walking in the woods when all of a sudden you spy a big snake curled on the path in front of you. The moment you see it, you jump backwards and then become completely focused on ensuring you’ve successfully escaped the threat, even though you didn’t make a conscious decision to do either of these things. They just happened!

The fight, flight, or freeze (FFF) response

This is the fight, flight, or freeze (FFF) response at its best. The moment your brain senses danger, it jumps into action to protect you. The FFF chemicals secreted during this process prepare you to fight off an attacker, flee from the situation, or freeze and hopefully go unnoticed.

The choice to fight, flee, or freeze is made automatically without your executive reasoning capabilities involved. Why? Because if you stand there deliberating about what to do (“is it really a snake? venomous or no? looking ready to strike or asleep?”), you’re likely to end up getting bitten.

That’s why when the FFF response is operational, our brains pull the plug on our executive reasoning capabilities. All those wonderful skills we use to thoughtfully process and analyze information in order to make well-reasoned decisions go offline, because in a true emergency, that type of deliberation slows down the process of protecting ourselves and can get us hurt or killed.

What does this have to do with OCD therapy?

When you’re in an active OCD episode, your FFF response is running.

It doesn’t matter that you’re not really standing in front of a snake. Once our brains either perceive a threat through direct sensory experience (I see a snake) or through a cognitive interpretation of an experience (I just ran over a bump in the road but what if it was really a person?), the FFF response goes into gear.

Once the FFF response is up and running, it’s unable to tell the difference between a real threat and a misperception of a threat. Why? Because our executive reasoning capabilities, that would normally help us make that distinction, have gone offline!

As I unfortunately experienced first hand in my own OCD recovery, when those of us with OCD spend a lot of time in therapy processing the content of obsessions, either through traditional talk therapy or cognitive therapy that is directly aimed at disputing intrusive thoughts, we’re often fanning the flames of the disorder. And if you’d like to read more about this, the IOCDF has posted an excellent article with more details.

Because our executive reasoning capabilities aren’t functioning property, we can’t process the rational reasons why the obsessions likely aren’t true. All our brains tend to take away from these conversations is something like…

“Boy, we’re spending a LOT of time talking about all this. I knew these thoughts were dangerous, and this confirms it! We wouldn’t be spending so much time trying to analyze them if they weren’t truly a threat. I’m going to put these thoughts in the super-important-we-need-to-figure-this-out category so that I can bring them up again and we can finally get certainty about whether they are dangerous or not!”

ERP, the evidence-based therapy for OCD

ERP, the evidence-based therapy for OCD, takes into account that our executive reasoning capabilities aren’t working too well when we’re in the throes of OCD.

Instead of talking about the fears and trying to change what we think (which is virtually impossible when the thinking part of the brain is offline), in ERP we do behavioral therapy to change our actions, to learn how to face our fears without doing rituals. Through doing different, non-compulsive actions repeatedly, our brains start to learn that we can be in triggering situations without doing rituals, and we can tolerate the anxiety and uncertainty that these situations create.

Over time, our thinking and our feelings catch up with our actions, as our brains learn that OCD isn’t about the content of the obsessions. It’s instead about uncertainty. And as I say in Fred, quoting my friend Jonathan Grayson, PhD, “the goal of ERP therapy is to live in a world of uncertainty and be happy anyway.” (p. 167).

Learn more about taming OCD

To learn more about how I used ERP to happily live in a world of uncertainty, see Is Fred in the Refrigerator? Taming OCD and Reclaiming My Life.  Click here to purchase your copy.