One of the important reasons why getting over OCD is so difficult despite every effort on part of the sufferer and the therapist is that there are some hidden compulsions that may not get identified. These may not only hamper the process of recovery, but also could act as enablers and could actually worsen the situation. One of the most common hidden compulsions that sufferers sometimes fail to recognize is the act of seeking reassurance.
“Are you sure the door is locked?” “Are you sure it is safe to touch the money?” “Are you sure we didn’t hit anyone?” These are all examples of reassurance seeking behavior. But these are not the only ways in which reassurance is sought. Reassurance is sometimes sought in other ways as well. Like a child asking his mother to check his homework before handing it in, is seeking reassurance. Like a wife asking her husband if he’s angry for her having spent so much money on a dress is seeking reassurance too.
Seeking reassurance as a child, when he wants to try something new and ‘dangerous’ like jumping off two steps and involves maybe just looking at the father who will encourage him to go for it, adding the words “you can do it”, is one thing. Where it begins to go out of hand is when the sufferer is scared of doing something un-scary (for the vast majority, at least), like touching a door knob and having to ask if it is ok to do so. Here’s why.
Let’s take a look at the phenomenology of OCD. OCD is a disorder of doubt. Crippling, draining, debilitating doubt. Despite repeated compulsions, or rather because of them, the doubt doesn’t go away. It in fact, gets stronger. The desire in the mind of an OCD sufferer is to always know without a shadow of doubt that his fear will not come true. Let’s say he is in the habit of checking the stove to see if it is turned off. When he checks it once, he’s not convinced. So he checks it again. And again. Multiple checks for something that needs to be checked just once, that too casually. Because of doubt.
Now as part of ERP, he needs to check it once and then stop checking it. Or in some cases, not check it even once. Which means, even if his mind does not believe it, he has to be ok with the uncertainty of having left it turned on. This causes him anxiety, but the anxiety will only dissipate if he learns to be ok with the uncertainty. Till then however, because of doubt, the anxiety that he feels can be enormous. At that point, if the sufferer is seeking reassurance, what actually is happening is that he is using a shortcut to deal with his anxiety. So,
checking >> doubt >> compulsive checking >> temporary anxiety relief
is replaced by
checking >> doubt >> reassurance seeking >> temporary anxiety relief.
Even if he’s not engaging in the compulsion of checking it again, he’s not really getting over the fear, because he is engaging in the compulsion of seeking reassurance. Moving from one to the other. It doesn’t help.
The idea in ERP is for the sufferer to exercise an acceptable level of caution, and disregard anything that goes overboard. If checking once and being ok with it is good for a non-sufferer, the objective is to make it ok for the sufferer as well. The only way, as explained in the ERP blog, is for the sufferer to tide through the anxiety. And reassurances derail that process.
Also sometimes, the reassurance seeking may not outwardly appear to be linked to any obsessions, but seeking them may still strengthen the OCD muscle, as one of my friends puts it. For example, if the sufferer fails to control his compulsions and asks his significant other, who is his therapist, if she still loves him despite the failures. There, if the significant other provides the reassurance that she does still love him, it could reinforce the thought that failing is acceptable. Which it is, but if it is equated with giving up is acceptable, that could become a problem. Thus, it is a fine balance that needs to be achieved.
So what do you do when a sufferer seeks reassurance? Firstly, when the treatment begins, the sufferer needs to be explained why reassurance seeking behaviour is not healthy. He is to be explained the difference between normal checking and reassurance seeking. He needs to buy into the difference so that when he is seeking it on account of his OCD and does not get it, the reaction is not explosive. Although despite the understanding and the internalising, reactions are often explosive when reassurances are not offered during anxiety situations. But they could be lesser with understanding, than they would be if the nature and the damaging impact of reassurances is not understood.
Secondly, as part of ERP, all the Anxiety Inducing Stimuli (AIS) need to be identified to ascertain which conditions reassurance will be sought in. There will always be surprises, but at least with this, the majority of them will be covered. Again, this needs to be explained to the sufferer during therapy, with a buy-in that the caregiver may refuse to offer reassurance when sought.
Thirdly, cognitively the obsessions need to be challenged, the cognitive distortions identified, and negated, and the rational alternative way of thinking presented to the sufferer, for him to draw upon when the obsession hits, Sort of like a repository of thoughts that counter his obsessive thoughts.
And then when the sufferer seeks reassurance, some version of the following three statements an be used:
1.You know you are asking for reassurance. I am sorry I will not give you that.
2. You know that this is an irrational thought. We have discussed this and worked out the logic.
3. You know what the rational thought is. Try to remember that and move ahead without the reassurance.
You may also decide in advance along with the sufferer, how many times reassurance can be sought in a day. Which should be slightly lesser than the usual number (neither equal, as it does not serve the purpose then, nor significantly lesser, as it will demotivate the sufferer if such huge progress is expected in such a short time). And when reassurance is sought, ask, “You probably know the answer to that, as we have discussed it. Are you sure you want to waste your reassurances for this?” This may get the sufferer to try and work without seeking reassurance for that particular incident.
These may not always work and ultimately reassurances may need to be given till better control is achieved. But that needs to be in extreme circumstances only, and more as an exception, rather than a rule.