Mental compulsions: The hidden OCD trick
By Nick Flower, Psy.D.
OCD: Hey Sarah, don’t you think you should unlock the door so that Anna can escape you if you start to abuse her?
Sarah: There’s NO WAY I would ever abuse her. I’m sure of that.
OCD: You can’t be sure of that so I really encourage you to unlock the door so you don’t hurt her. Remember, I’m here to keep you and your daughter safe.
Sarah: I’m a good person…I would never hurt my daughter.
OCD: No you’re not. You will hurt her if you don’t unlock that door!
The effects of OCD are most often thought of in terms of what rituals (or compulsions) are able to be seen like hand-washing, checking, locking the door, etc. But many times the rituals of OCD can take place behind-the-scenes in the form of mental compulsions. Like Sarah, many people who have OCD have primarily mental compulsions and this phenomenon has come to be known, erroneously, as Pure-O OCD.
OCD compulsions come in two distinct but very related categories: Outward/behavioral and mental compulsions. Outward behavioral compulsions are something that everyone can see. Things like checking to see if the toaster is really off or that the front door is locked. Or excessively washing your hands or scrutinizing skin for signs of cancer. These are the obvious compulsions that are often easily recognized and addressed in OCD treatment.
Mental compulsions are, to a degree, trickier because they are hidden and out of sight in the mind but they operate by the same rules of negative reinforcement that perpetuate the OCD cycle of obsessions and compulsions. Remember that obsessions are thoughts, images, urges that cause anxiety or disgust and compulsions are actions (thoughts or outward actions) that the person does to reduce or avoid anxiety. It’s ultimately the compulsive behavior that brings about more obsessions.
Examples of mental compulsions are: Using a “good” word like heaven to replace a “bad” word like hell; Saying a silent prayer that the anxiety will go away; Wishing for a scary event to be over; Telling yourself that “This is just my OCD, not a real fear;” A statement like: “The doorknobs in Dr. Flower’s office probably aren’t that contaminated;” Wishing that you’d rather not have OCD in the first place; or even sometimes telling yourself that it will be alright. Mental compulsions like the ones just mentioned are sneaky and insidious but still just as bad as the outward behavioral rituals that are more recognizable. They all serve the purpose to reduce or avoid the anxiety and/or disgust brought on by the obsessions.
Treatment interventions in exposure and response prevention therapy (ERP) must be targeted to address both types of compulsions: the outwardly performed, tangible compulsions and also the mental compulsions. This is done through the typical ERP model with exposures to feared situations and combined with ritual prevention. This behavioral/action approach of ERP is combined with cognitive therapy which includes some version of the person using effective self-talk to challenge the OCD. My patients have often found it helpful to learn how to “talk back” to the OCD in the same fashion they might to a bully who is picking on them. Once the bully is made aware that his insults don’t effect you in the way he thought…he is diminished and usually goes on to the next potential victim.