In treating OCD, the key is ERP (exposure and response prevention). In carrying out ERP, often the key is finding an underlying, or “core” obsessional fear. That is not always easy to do.
I was talking with a smart, devout Christian student who was suffering the obsessional fear that she was homosexual. She had no actual inclination in that direction. It was clearly an OCD fear, and she realized that. As every OCDer knows, however, possession of insight is not enough; because at the time a fear strikes, it tends to run away and hide. So, this student was really suffering when I saw her. She was so anxious she couldn’t even lift her eyes to look at a woman.
She happened to know a good deal about OCD, as she had suffered the disorder since adolescence, and had received competent therapy. She was taught how to do ERP, and used it with good effect in treating handwashing compulsions. When we got together, therefore, she thought she knew what she had to do. Taking a deep breath she asked, “Do you think I should do ERP on the homosexual images and thoughts?” We agreed by the end of the session to give ERP a try.
“It didn’t work,” she said upon returning a week later. “I hardly got anxious. It’s like…well, I know I wouldn’t really do that sickening stuff. Doing the ERP is like watching a picture of someone else. I know I’m not that way, and never will be that way, so it just didn’t work.” We tried to identify the underlying fear. What was the very worst thing about those thoughts and images? Finally, she said, “I think it is that I’m messed up internally. It’s like everyone thinks terrible thoughts, I know that. But I react differently. And because of that, I wonder if I am messed up internally. Maybe I have a predisposition towards homosexuality. I think that’s what the fear really is.” After discussing this for a while, we decided to write an ERP script based on the anxiety producing thought, “Maybe I’m predisposed to homosexuality, and letting down God.”
“It didn’t work,” she announced upon seeing me the next week. “When I thought about it, I know that God gives grace to people with predispositions that are abnormal. God came to save sinners, not the righteous. God isn’t disappointed with me. God loves me!” I began to have a sinking feeling. We explored further her sense of being “messed up internally.” As she talked, she offhandedly explained—like it was so obvious it didn’t deserve comment—“God will give you grace, but you must fight your bad instinct.” Finally, an “aha!” moment. “Wait a minute,” I said. “You don’t have a bad instinct. You have OCD!”
“That’s the fear!” she said. “It’s not that God wouldn’t give me grace because I’m homosexual, but that I would have to fight that instinct every day. Maybe I’d have to fight it my whole life!” This was the key. How hard it sometimes is to get a handle on the fears that cause OCD. After this clarification, she was able to realize the irrationality of that idea, the core fear, and do effective ERP in order to habituate to it.