1. Life will get harder when you work on your OCD.
When I started ERP, I expected a roughly linear recovery path. "Yes, there may be some bumps along the way, but surely my symptoms won't get worse on the whole." In my case, at least, they did get worse; they're still worse. And yet, in a sense, I have been steadily getting better. For much of my treatment, I confused symptom severity with therapeutic progress. The two are not the same, and for a time, they can even negatively covary.
In ERP, you typically tackle your least distressing obsessions before progressing to your most challenging obsessions. Pause to consider the implication: If you start by getting rid of the stuff that makes you feel kinda bad, and you've left yourself with only the stuff that makes you feel really bad, and you're depriving yourself of the coping strategies that made you feel safe for years or even decades, then of course you'll feel worse precisely when you've made progress. Beating OCD is like playing a video game with progressively harder boss fights. The game doesn't get easier as you make progress; it gets harder. But the more bosses you beat, the closer you are to winning.
At the same time, you haven't won the game until you've beaten all the bosses. If you've patched up 99 vulnerabilities and left 1 open, OCD will throw its entire weight behind exploiting that lone vulnerability.
The appropriate attitude, then, is to approach OCD like you'd approach a Soulslike. Expect difficulty to increase with progress. Expect harder battles to require more attempts than easier battles. When a battle is too difficult, increase your abilities with "side quests", then return to the scene. (Battling without the appropriate gear may lead you to quit altogether.) And don't stop until you've beaten the final boss. As you tackle your final trial, success will feel impossible. Victory hinges on bracketing your frustration and persevering through immense resistance.
2. You are not guaranteed success.
This isn't to say that success isn't possible or even likely. But it is to say that, as with everything in life, success is uncertain. ERP doesn't work for everyone. SSRIs don't work for everyone. We don't always know why. Everyone with OCD has to decide for themselves whether the risk of trying to get better is worth it.
3. Happiness is not the goal of therapy.
Your therapist can't make you feel better. You can't make you feel better. While "feeling better" is often a salutary byproduct of therapy, it is not the telos of therapy. The aim of behavioral therapy is there in the name; it's about changing your behavior to align with your values. The psychological comfort that you seek is not the goal; a comfortable life might not come out of successful therapy. If you're able to live a meaningful life devoid of compulsive behavior despite your anxieties and obsessions, that's success. And if you free up capacity to help other people and perform good deeds, that's ideal. Therapy isn't actually about you; it's about everyone around you.
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4. You will always have OCD, and you will always be at risk of relapse.
Full and lasting remission from OCD is technically possible—especially if you catch it early—but for many of us, the goal is management not elimination. However, management is not the same as toleration. A host of chronic conditions can be fully managed, meaning that they no longer meaningfully interfere with daily functioning. Some auto-immune disorders, for example, are chronic yet have minimal impact on one's life with simple management steps such as taking a daily pill. The same goes for OCD; with consistant maintenance work, you may be able to bring yourself from functional impairment to sunclinicality. But someone who uses compulsions to tolerate their OCD is like a hypothyroidic person who skips their dose of levothyroxine. To commit yourself to management is to say: "I can't cure my OCD, but with vigorous initial treatment followed by daily maintenance, I should be able to live a largely—or maybe even fully—functional life."
5. You may have had a more enjoyable life if you hadn't had OCD.
I often compare my life to others' lives. The comparisons I conjure up seldom favor me. Self-pity is a stable fixture in my rumination rotation. I think about how much of my life I've lost to OCD, how much happier I would have been without OCD, how many blessings I've failed to appreciate because of my OCD, everything's terrible, nothing's good, I should have had the "worst life" superlative in my high school yearbook.
There's an obvious response to this somewhat embarassing line of thought: Many people's lives would be better if they didn't have their condition. Those with major physical disabilities, with childhood traumas, with loved ones lost too soon, etc., would likely have had more enjoyable lived if they didn't fall victim to their conditions or circumstances. That's just life. But when you're in the depths of misery, this tu quoque doesn't hit the same. Suffering is near-sighted.
During a therapy session where I could hardly stop sobbing, my therapist asked me: "What do you want to see in your obituary?" The concept he was getting at isn't radical. It's simply the observation that the value of one's life isn't determined by the balance of pleasure to pain. Most of us don't rank lives based on an hedonic calculation, and for good reason. Many valuable lives were filled with immense pain, and many wasted lives were filled with seemingly endless pleasures. Living happy is not the same as living well. Those of us who have suffered from OCD might even be in a favorable position—albeit a position that, on an average day, I'd readily trade for a bag of potato chips. We have learned the hard way that happiness and comfort, when pursued directly, are empty pursuits. Living well has to be about more than this. If it isn't, life is a farce, and not just for us obsessives.
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6. "Why me?" is a silly question.
Why not you? What makes you so special? Are you less deserving than everyone else? This might sound cold, but obsessive people can use a splash of cold water every now and then—literally and figuratively. When you ask "Why me?", you're asking a question you know to be unanswerable, and you're squarely in your own head. To get over OCD, you first have to get over yourself. That starts with refusing to luxuriate in your own depression.
7. Indulging in compulsions is selfish.
When under the spell of OCD, I convince myself that that the moral course of action is that which OCD dictates. The tension between "OCD voice" and "real self voice" (or, more often, between "OCD voice" and "exasperated wife voice") leaves moral questions unresolved. OCD is unrelentingly didactic, and it will not abide unresponsiveness. "You know what the right thing to do is," OCD says. "It's what I've been shouting at you for days, weeks, years!"
When OCD reaches a certain volume, its deliverances feel self-evident. How does one adjudicate between the OCD voice (which always presents as the moral voice) and counterveiling voices? Ask yourself what the voice really wants. If the answer is "peace of mind", it's OCD.
Your disorder pretends to care about morality, but it doesn't really. To frame it in crude Kantian terms: OCD never acts from the moral law. Its goal is always and only psychological comfort, and it prescribes compulsions to achieve it. Psychological comfort is about you: not morality, not other people, not God. And so compulsions—even those which present as moral imperatives—are fundamentally selfish. This is an analytic truth.
People with moral and religious scrupulosity regard psychological comfort as the inevitable reward for leading a moral life. It's not. Moral exemplars can feel guilt; saints can experience psychological pain. To do the truly right thing even while suffering from pathological guilt is to give without counting the cost.
8. Showing up to your therapy sessions isn't enough.
I treated a lot of my early therapy sessions as supercharged reassurance-seeking sessions. Who better to reassure me than an OCD expert? And thus the questions began: "Do you think it's safe for me to drive? Does this memory sound like a false memory? How do I know that I'm not going to harm someone?"
In the earliest days of therapy, these questions may yield some decent psychoeducation. But once you have the scouting report on your opponent, they're just distractions. Focus on your exposures, and sit with uncertainty. Your therapist doesn't have some mystical, arcane insight that will transform your condition overnight. Good ERP therapists will train you to employ an evidence-based system for behavioral improvement. Really good therapists will give you encouragement and help you through particularly grueling moments. Expect nothing more, and ask for nothing less.
9. Medication alone probably isn't enough.
Magic has a way of losing its magic, at least in my experience. For me, the magic started with Zoloft. It cured everything ... until, 6 years in, it stopped curing everything. Then Prozac was the answer ... until, 1.5 years in, I experienced a breakdown. In both of these cases, I used medication and compulsions to tolerate OCD (see #4), and that approach worked for a long time. But as soon as I was hit with major life stressors, I didn't have the skills I needed to manage my condition. I was simply using medication to tolerate.
Tolerating OCD is like walking a tightrope. It's feasible so long as you never encounter a strong gust of wind. When the weather takes a turn for the worse, you fall from a great height.
10. You might get it wrong.
You might write off something as "just my OCD" that isn't OCD. You might make a moral mistake as a result. Afraid of going too far? You might. And you'll only heal when you accept that possibility.
The "safe" life that OCD offers is a half a life. If you want a full life, you have to accept the possibility of catastrophe. There are no other options
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