Why does my obsession feel so real?

And here we are, back to a new academic year! I’m one month away from submitting my thesis, which takes up 90% of the free time my clinical work leaves me, so there’s not much left for anything else. Between the thesis and my work with patients, the world of OCD is taking up a lot of space in my head right now, so it couldn’t be any other way: today I’m going to talk about it, and specifically introduce one of its key elements: OCD narratives, or OCD stories. It’s a tricky subject and, as always, I’ll try to make it as easy to read as possible so you can take away the key ideas and put them to use.

Inference-Based Cognitive Behavioral Therapy (I-CBT) gives narratives a central role in keeping obsessive-compulsive disorder going. Broadly speaking, narratives, or inner dialogue, are everything we consciously say to ourselves: the way we talk to ourselves when we interpret whatever happens in our lives, from the most trivial to the most important. Well, an OCD narrative is everything the person tells themselves to make their obsession credible. In other words, all the arguments that make the obsession seem more real, more rational and, therefore, justify considering it. Like any story, the more elaborate and nuanced it is, the more power it has, and so does the obsession. OCD is a very clever disorder, as clever as the minds of the people who live with it, so it’s going to sell you its story very well, because for a thought to cause anxiety it has to be believable. If you don’t believe it to some extent (consciously or unconsciously), there’s no physical or emotional response. OCD is going to sell you a piece of junk, but it’s such a good salesman that you’ll buy it. And it’ll cost you dearly. The junk is the obsession, and the marketing strategy is the OCD story.

At first glance, the arguments in an OCD story will always seem rational because of their content (the what), but if we look more closely and examine the how and when (the context), we’ll see that none of them is based on the person’s here and now, that is, on their reality. Every argument in any OCD story, in any type of OCD, comes from the person’s imagination, not from their context. This last point matters because the obsessional doubt becomes 100% irrelevant the moment it isn’t grounded in the here and now. For example: the only reason I’m not worried, as I write this, that someone I love has had an accident is that nothing tells me it’s happening or has happened. My context isn’t giving me any information that justifies that thought. If I glanced at my phone and saw ten missed calls from a friend, if I’d received a worrying message, or if the police knocked on my door, then my here and now would justify that thought and the worry that follows. As long as none of that is happening, the thought is irrelevant.

The main difference between obsessional doubts and normal doubts is that normal ones always have some basis in reality. When I want to know a patient’s OCD story, I always make the same request: I’d like you to write down everything you tell yourself that makes the obsession seem real. All the arguments that make it believable, even though you know (in your “clear-headed” moments) that it’s absurd. For example… (and here we pick an argument from their own case to help them build their OCD story). And I want you to be thorough, to take the trouble to think of every last argument and write it down. The more detailed, the better.

There’s only one type of obsession that is the exception to the rule and has no OCD story behind it: just right obsessions (where the person needs to do, place or think something in a particular way simply because, from a sense that that way it’s right). Every other obsession, whatever its nature, has an OCD story behind it.

Let me give you the example of Pablo (17), whose obsession was “What if I hurt my little sister?”. This is how Pablo argued it in his OCD story:

When I was little I often got into fights with other boys at school, which means I was an aggressive kid, and if I was aggressive then, maybe I still am. Maybe I’ve still got all that anger inside and I could lose it and let it out, and who’s to say I won’t let it out on my sister one day? Sometimes when she winds me up I feel like telling her to get lost and slapping her, so who’s to say it won’t get out of hand one day? It happened to a friend from school with his little brother, and they got on well. Sometimes I’ve had nightmares where I was shouting at my family and hitting them, especially if I’d been angry with them that day. People lose it, you only have to watch the news. What if one day I actually decide to hurt her? What if I pick up a knife like the one in that documentary I told you about…

OCD stories need to be identified, and for that the person has to understand very clearly what an OCD story is and then tell their own. Later, the story is analysed so that, through a process, the person realises that the marketing strategy is very good but the product doesn’t hold up. The final step after this process (which is neither easy nor short) is to build a non-OCD story: a narrative based on facts, on the senses, with no room for imagination, “what ifs” or anything like them.

This process, which may look simple to someone who doesn’t have the disorder, is a long and very hard road. Whenever a patient asks me “but can OCD really be cured?” (to begin with, “cure” isn’t the right word here, because we’re talking about a disorder, not a disease, but let’s not get into that now…), my answer is always the same: yes, OCD can disappear completely. Does it always? No. Sometimes it doesn’t improve at all, but in my experience those cases are very few. Usually, if the person works well and works hard, OCD improves significantly. If they work little, badly or “on and off”, OCD stalls and gets worse over time. For those who work well, how far they improve will depend on many factors, but I always say the same thing: I can’t guarantee you anything, because I’d be lying, but what I can promise you is that the more you work, the better your results will be.

In memory of Kieron O’Connor, founder of Inference-Based Cognitive Behavioral Therapy.