CBT and the NHS

I started this intending to write about the exposure work I’ve just done, but it turned out I have a lot of thoughts about exposure therapy for OCD, and the NHS provisions for OCD, so I’ll put them here and write a different blog about today’s exposure.

Cognitive behavioural therapy for OCD

The recommended treatment for OCD is cognitive behavioural therapy (CBT) combined with medication (usually antidepressants). One component of CBT is exposure therapy, which involves repeatedly approaching the thing that makes you anxious (yes, it is a brutal form of therapy). Usually you’ll rate your symptoms in a hierarchy of the least difficult to the most difficult, then you’ll start with exposure to the least difficult, and move up the chart. The theory behind it is that when you first encounter the frightening object/situation, your anxiety will spike, but if you stay with that anxiety then it will gradually come down. With practice, the initial spike of anxiety should be lowered.

This technique works pretty well for things like contamination OCD. For example, touching a toilet seat and not washing your hands – this would initially cause a lot of anxiety, but over time the idea is that this anxiety will decrease. In this example it also allows the individual to collect evidence that they have touched the toilet seat and neither they nor people around them have dropped dead from germs. Exposure alone is not so good for religious themes, in my opinion – I could do the things that OCD tells me will send me to hell, but there’s no way for me to see that this won’t send me to hell.

My previous experiences with CBT for OCD

The good

In 2012 I had successful CBT for religious OCD. It did involve exposure, but we spent months working on cognitive reappraisal before I attempted the exposure. This strategy worked, because although exposure was terrifying, I could fall back on my logical arguments that showed me that OCD was lying. In this case the cognitive reappraisal took the place of the “evidence” that I might have had if I was dealing with a different OCD thought (e.g. evidence that no one died following contamination based OCD exposure). It also helped that my therapist had an in-depth understanding of OCD and was a Christian, which allowed her to easily differentiate between what was OCD and what was typical for other Christians (e.g. praying for forgiveness is typical, but compulsively doing so can be OCD). This was before the NHS “reforms” really started to bite, so I was able to have quite a long period of CBT before it had to end because they were prioritising people with “more severe” conditions such as psychosis, and I wasn’t suicidal. Thankfully we’d done enough work that I was able to continue improving over the following months even though I wasn’t having therapy.

The bad (sort of)

In 2016/17 I had unsuccessful CBT for religious OCD (I had stayed well for about two years after the 2012 CBT, but had got ill again). This was with an IAPT therapist who, as far as I know, wasn’t specialised in treating OCD or religious OCD. She was very focused on exposure and not keen on me using cognitive reappraisal. I told her that beginning with reappraisal had worked for me before, and that I had had many years’ experience with CBT and knew what had and hadn’t worked (I had had a lot of less successful attempts at CBT prior to the successful 2012 attempt I described in the previous paragraph). Unfortunately she was worried that if I focused on reappraisal it would end up being rumination (which is a symptom of OCD). This is a valid concern in general, but it wasn’t appropriate in my case as I had 2 decades of experience with the way my OCD operates and 10 years’ on-and-off experience with CBT for my OCD.

I did have some success with the exposure therapy with her, but I had lost confidence in her because she wasn’t willing to adapt according to my experience, so I think that limited the success I could have had. Having said that, I remember feeling that I was working harder than I had done in 2012 when I’d actually got better, so it wasn’t simply to do with my level of effort. Eventually I had to say something along the lines of: I’m not willing to go further with exposure unless we work on cognitive reappraisal. She accepted, but by this point I had nearly come to the end of the 20 sessions that the NHS allows. I was a bit better at the end of that course of CBT than I had been before it. However, that lasted about 2 weeks(!) Shortly after I finished CBT one of my heroes died by suicide – my OCD reacted by getting the worst it had been in years, and it’s pretty much been stuck there ever since. In order to get higher-level help the waiting list would have been 12 to 14 months. Due to my work I didn’t know where I would be living in 12 months’ time. In addition, in order to access that help I was led to believe that I’d need to go via the person who had given the CBT, and I felt awkward about that. I gave up on trying to get NHS help at that time. However, I’ve approached the NHS for an assessment in the place I live in now, so we’ll see what happens. (As it turned out I did end up moving about 250 miles away for work around the time I would have reached the top of the waiting list in that area).

The ugly

Just to make the titles match up nicely, here’s a brief description of a psychiatrist providing “ugly” CBT, from around 2009 before all of the above happened. At the time one of the things my OCD was focusing on was HIV (either that I had it and would give it to others, or that I would catch it from others – it tended to switch between these two, even though logically that makes no sense). I had a cut on my finger and the psychiatrist wanted me to touch the cut to the arm of the chair I was sitting in. I told her I’d had CBT before and was aware of what level of anxiety-increase is therapeutic, and this was too far, but she insisted. I ended up doing it and then rushing in a panic to Tesco after the therapy appointment to buy plasters to cover up my cut. This undid the good work I’d achieved in leaving the cut uncovered. At one point that psychiatrist even said something to the effect of “I can do it so why can’t you?” Not a good experience of CBT.

Back to the good again!

To end the blog on a more cheerful note, I am currently having a small amount of success using CBT techniques with an OCD specialist – we’ve recently started working on exposure. My next post will talk about the CBT I’m doing right now with this new therapist.

I’m privileged that my parents can help me to pay for this private therapist who has expertise in OCD, though I feel a bit ashamed that I am accessing private mental health care when many people can’t. I partly justify it to myself by considering that my job involves improving other people’s lives, and if I can get well then I can devote more energy to my job, though this justification feels a little hollow. I hope that in the future I can pay for high quality, easily accessible mental healthcare through my taxes instead.

David Harewood’s Psychosis and Me: Thoughts from someone with OCD

It’s important to preface this post by saying that I don’t have a huge amount of knowledge of psychosis – probably more than the average person but nowhere near as much knowledge as I have about OCD. So if you have psychosis and spot something which isn’t right, feel free to let me know!

First of all, I think I speak for many people who have mental illness in saying how pleased I was to hear a celebrity being so open about his experiences with psychosis. David Harewood: Psychosis and Me (at the time of writing, available on BBC iPlayer) was an interesting programme to watch, and reminded me of some of the similarities and differences between psychosis and my own experience of mental illness.

Similarities

The “third party voice”

The part of the programme that resonated with me most was this quote from a woman who is currently managing her psychosis fairly well. She’s talking about how she deals with the voices when they do come up:

Remind myself that this type of thing has happened before, and it’s just my third party voice. Don’t have to listen to it, certainly don’t have to answer to it, it’s just my third party voice, get on with what [I’m] doing.
person with experience of psychosis

I liked the conceptualisation of psychosis voices as a “third party voice”. The way this woman approaches her voices is similar to the way I used to approach my OCD when I was well and got the occasional intrusion. It’s also what I aim to do with some of my bad thoughts now, when I’m trying not to obey them all (I usually make some attempts in each day, but the number of attempts varies depending on how tired and stressed I am). I’m not always successful, but if I can catch/dismiss/ignore an OCD thought right away, it’s easier to move past it than if I “enter into a conversation” with the thought or give it any serious response. OCD tricks your brain into thinking there is an immediate threat – it co-opts the neural circuitry that was designed to keep us safe from physical danger. It’s very hard for your brain to over-ride that – if it were easy we would have died out as a species many years ago.

So the quote from the woman with psychosis is a good example of what relative recovery looks like, in psychosis and in OCD. For me, recovery from OCD involved maybe 5 bad thoughts per day, all of which could be ignored easily. That was like living in a world of colour, compared to the grey I lived in before it.

The structure and content

Another similarity between psychosis and OCD that came out of the programme was to do with how the psychiatrist noted that the structure of psychosis is similar across people, but the content varies. In addition, the psychiatrist talked about how the content of psychosis varies in line with society and the things that are important to the people involved. So psychosis now can involve social media, whereas psychosis in the past more commonly involved religious themes. This is quite similar to OCD in that the intrusive thoughts and the compulsions are often similar across people, but the content depends on what matters to the individual. I’m fully aware that if I have children, my OCD is likely to focus on causing harm to them, because they will be one of the most important things in my life. My OCD now is focused on religion, because my faith is important to me (and also because it’s been the hardest OCD theme for me to beat).

Talking of which, that brings me to another similarity – a woman who was very unwell on the programme said that the devil put something in her neck, and that the devil was in things and people. This reminded me of when I was younger and I had a bad thought that Jesus was in my dad’s slipper. My dad ended up throwing the slipper against the wall in frustration, which didn’t help.

Differences

Do you truly believe the intrusions?

To someone with no experience of either mental illness, I’d imagine psychosis and OCD can sound similar on the surface. The best way I can think to distinguish them (bearing in mind I haven’t personally experienced psychosis), is that when someone with psychosis gets very unwell, they genuinely believe their delusions, and will express them to others without much awareness that they will sound strange (e.g. David Harewood telling his friends he had three brains). A person with OCD who is very unwell often does know that their thoughts will sound preposterous to a neurotypical person (e.g. I know that “my mum will get cancer unless I count to 10” will sound odd to people without OCD). To varying degrees, people with OCD know that the thoughts are intrusions. But we still react to them because they feel as terrifying as they would if they were true.

To look at another example (this could be potentially distressing, so feel free to skip to the next paragraph), a woman in David Harewood’s programme talked about when she walked in front of a white van because she believed she could save her family by doing so (in a supernatural way – she wasn’t suicidal). Thankfully she survived (she said she ran away afterwards, so I assume she wasn’t too badly injured). But as far as I could tell from her telling of the story, there was no other interpretation in her head at that time, it was just something she “knew” she needed to do. In contrast, I’ve found that if my OCD has to compete with genuine life-threatening situations, it quietens down. For example when I was in an emergency lay-by next to a 70mph road, I was able to walk away from the car without the usual onslaught of bad thoughts telling me where to step. With OCD there is always a tension between our knowledge and our fear. [As a side note: writing this paragraph meant my OCD started trying to convince me to walk in front of a van in order to stop my worst fears happening – OCD works with what’s there unfortunately].

I should point out here that I know that some people with symptoms of psychosis, such as hearing voices, often do know that the voices are generated by their own minds. Similarly, people who used to believe in their delusions wholeheartedly but have since had successful treatment can have good insight into what’s real and what’s a symptom (as demonstrated by the woman on David Harewood’s programme, and David himself). The difference between OCD and psychosis is perhaps clearer when it comes to first episodes of psychosis and the people who are the most unwell. From what the programme suggests, people who are very unwell with psychosis are unlikely to be fully in touch with the real world. In contrast, I am severely ill with OCD but I almost always know when a thought comes from OCD and when it comes from me.

Treatment effects

Another difference is that symptoms of psychosis can show dramatic improvements if people comply with their medicine. At least in my experience, this hasn’t been the case for OCD. Despite my initial high hopes, I’ve never noticed a reduction in the strength or frequency of OCD thoughts as a result of taking medicine (even at high doses, and even having tried multiple medicines). It’s likely that this is partly because I’m not personally very responsive to anti-depressants, for whatever reason. But I suspect that medication for OCD in general isn’t linked with the vast improvements in symptoms that have been described by people with psychosis.

There was a lot of talk in the programme of “if I’d got help earlier” or “if I’d taken those tablets” then things wouldn’t have got so bad. I don’t know how true that is of people with psychosis in general, vs how much it was the programme encouraging people to seek help early. But from what I can tell some people with psychosis can see a big, relatively fast improvement in their symptoms if they are prescribed the right medicine, and so intervening at the right moment can make a big difference.

It’s generally correct that the earlier you can get treatment for mental illness the better the prognosis. However, I wouldn’t say there was a moment where I could have stopped myself getting this ill if only I’d done x at time-point y. [In hindsight, not entering into an emotionally abusive relationship would have given me a better chance at getting well sooner, but I didn’t have the self esteem to make a different choice at that time, and I had already been ill for 8 years by then.] When my OCD was presented with medication (at age 17), it just barreled on through. Maybe it would have been different if I’d been given medication at age 11, but I suspect not – my genetics and life circumstances would have been the same, and both would have continued to play their part in maintaining and worsening my illness. [Note – this isn’t to say that there was never any hope – I did get better at age 23 and I am hoping to get better again]. I’m glad that medicine can have such a positive impact for some people with psychosis, and I hope that one day treatments for OCD will catch up.

A wolf in sheep’s clothing: how to address OCD concerns that look “normal”

This post is intended to help both people with OCD and those who support them.

Sometimes OCD sounds absurd (e.g. “my mum will die if I touch the sofa”). However, sometimes OCD looks like an extreme version of an everyday concern. For example, someone may be worried about getting germs from a door handle. It’s perfectly possible for this to be either a) a symptom of OCD or b) a concern held by a neurotypical person who is conscious of hygiene. (As an aside, if you want an excellent example of how it feels to be “stuck” in a bathroom because you can’t touch the door handle, watch The Aviator, a film about Howard Hughes who had OCD).

These thoughts look the same on the surface, but they behave in very different ways. I’ve written elsewhere about how to tell if the thought is OCD or not. Here I want to look at how the best response to an OCD thought can be very different to the best response to a non-OCD concern.

Example: Contamination fears

The other day a friend of mine was concerned about contaminating her bed sheets. She was having OCD-driven thoughts that her body would get germs on the sheets. A mutual friend responded to my friend’s concern by suggesting that she could wipe the sheets with a wet wipe or similar. This is a logical solution to the apparent problem, but when the problem comes from OCD, this solution is unlikely to help.

I want to reiterate that I am not diminishing our mutual friend’s attempt to help. Rather, I want to show how the nature of OCD means that advice which would work for a neurotypical person with exactly the same problem wouldn’t work for a person with OCD.

One of the many ironies of OCD is that whilst we can spend hours seeking reassurance that something is safe, ok, or clean, we rarely succeed in accepting that reassurance. No matter how many rituals you do or how many times you repeat an activity, it won’t feel ok (although that doesn’t stop OCD lying that if you just do it one more time you might be able to make it “safe”). I read an interesting paper suggesting that this might be because a specific part of the brain has difficulty sending “safety signals” which tell the rest of the brain that the situation has been resolved. After reading that paper I found it helpful to think to myself “my brain can’t make me feel like it’s ok, so I have to choose to believe that it’s ok”. (Cognitive reappraisal helps me with this – more about this at the end of the post).

So to return to the example, if my friend had wiped her bedsheets, she may have momentarily felt ok, but soon enough the OCD would return and she would worry that she hadn’t wiped them thoroughly enough, or that the cloth she used to wipe it had germs on, and so on.

This ties in with another aspect of OCD that has come out in research – we often over-estimate the extent to which germs can contaminate objects. For example, say I were to touch a toilet seat, and then touch my phone. I then wash my hands and get on with the day. I later make a call on the phone, and later lie down to go to bed. My perception might be that the germs from the toilet seat had transferred from my hands, to the phone, to the side of my head, and on to the pillow. Most neurotypical people don’t think in this way – I sometimes see other women doing their hair in the bathroom mirror before they wash their hands from going to the toilet. I only have mild contamination symptoms these days, but this is an example of something that bothers me that most neurotypical people wouldn’t even notice.

Thinking back to my friend’s situation – my advice would be to think about the fact that people are responsible for their own health. If anyone else sleeps on the sheets, that is their choice. Think about what a neurotypical person would do, and copy that. If a neurotypical person accidentally wets the bed, they may think about germs, and they will change the sheets. Otherwise, they won’t think about germs. Society survives with, and even needs, a certain level of germs. If you are within the boundaries of what a neurotypical person would do, you have done enough. Protecting other people from germs is not your responsibility.

So, in summary, don’t be dismayed if your OCD or your loved one’s OCD persists in the face of advice that would calm a neurotypical person. Sometimes you have to take a different path to the one that seems intuitive to neurotypical people. The more you read about OCD, the more you will learn about what is likely to help you or your loved one. Cognitive reappraisal is a technique which I have found very helpful. This often involves writing down arguments for and against your OCD thought (usually there will be very few arguments on the OCD side!), and reassessing how you think about a situation. The paragraph above, which describes other ways of thinking about a contamination fear, is an example of cognitive reappraisal.

Nuts!

Content note: if you have particular difficulties with contamination OCD or OCD focused on your perceived responsibility for other’s health, read on with caution.

When I was a young teenager a lot of my OCD thoughts were focused on preventing harm to other people. I had a period where I took care to make sure I didn’t cause a scuff on a carpet, in case someone tripped over, banged their head and died. I was very nervous around fire extinguishers in case I somehow damaged them in some way: if there was a fire and the extinguisher didn’t work because I had brushed past it, people might die. My OCD made me feel that these deaths would be my fault.

One way in which I worried about harming others was by eating or touching nuts. When I was a child/young teen I ate peanut butter sandwiches and Tracker bars with nuts in. However over time I couldn’t bring myself to eat them anymore, as I was so afraid of harming someone with a nut allergy. It became too much effort to try to make sure I avoided touching any nuts whilst eating those foods and/or make sure I could wash my hands immediately after without touching anything in the environment.

There was a girl in my class with a relatively severe nut allergy (she had to leave the room when we were burning peanuts in a science lesson – not sure why the teacher asked us to burn peanuts, something to do with energy). However I wasn’t only scared of harming her, I was scared of harming some unknown person who might have a nut allergy. For example, if I touched a nut and then opened a door I might transfer the essence of the nut onto the door handle. If the person who touched the handle after me had a nut allergy, they might die and it would be my fault.

I remember once being very distressed because we were playing a family game that involved passing a console around the group. My dad (and possibly others) were eating peanuts – I think it was a Christmas snack. I was really anxious about touching the console after someone who had handled nuts had touched it. It’s important to point out that I wasn’t going to be seeing any one with a nut allergy that day, or for many days after. It’s still making me feel tense to write about it though, about 16 years later.

I’m better than I used to be with nuts – I can eat peanut butter sandwiches and breakfast bars containing nuts. If offered a nut from a bowl I probably wouldn’t take one though, especially if I couldn’t wash my hands immediately after. Then again I’m not keen on eating food that other people might have touched anyway.

How to overcome this

I don’t remember treating this OCD fear in a direct way – it wasn’t really necessary as it wasn’t constantly interfering with my life like some of the other thoughts were. To some extent it faded naturally as my OCD morphed into other themes.

However, there are two cognitive factors that I’ve found helpful with this kind of compulsion. One is that it falls under the banner of “things that are biologically wrong”. The majority of people’s nut allergies are not so severe that they could be harmed by touching a door handle after someone who had just handled nuts. If they were that sensitive, they wouldn’t touch public door handles, which brings me onto the second factor…

You are not responsible for other people’s safety! Other people are responsible for their own health and safety. Repeatedly reminding myself of this fact has been helpful for me when I get these fears. I’ve built up my belief in this reality over many years, and now I’m towards the edge of the “normal” range of concern for other’s health – just a little more concerned than the average person. I’m happy with that.

Anatomy of an OCD thought: Part 3 – fighting back

Click here to read Part 1.

Click here to read Part 2.

CONTENT NOTE: As with parts 1 and 2 please take care if you have religious OCD or OCD which focuses on magical thinking (i.e. if I do x then y will happen). However, I hope this post will be helpful for people who have similar OCD thoughts as in this part I will attempt to show why OCD is wrong.

The OCD situation I discuss here is described in detail in Part 2, and the OCD rationale behind it is described in detail in Part 1. In this part I am aiming to show myself (and others with similar thoughts) why OCD is wrong using cognitive reappraisal techniques.

What does OCD say?

I “know” (because OCD has told me) that what I did meant I was insulting the Holy Spirit and the devil.
They can hear my thoughts and know this too. Therefore they will be insulted unless I make it safe.
I used my middle finger because I was intending to insult the Holy Spirit and the devil.

What are the arguments against what OCD says?

OCD is a mental illness. The thought is the symptom of an illness. If I didn’t have OCD I would not have had this thought. OCD is a mental illness which focuses on the things that matter most to the individual with OCD, and the things that cause the most fear to them. However it is a symptom of an illness, in the same way that someone with psychosis may believe they are Jesus, or someone with meningitis may get a rash. The exemplar person with psychosis believes they are Jesus, this doesn’t meant that they are. The person with OCD believes that their actions are insulting to the Holy Spirit or the devil, this doesn’t mean that they are.
Christian arguments against the thought (re. the Holy Spirit). The Bible says repeatedly that God knows everything, He is omniscient. That means He knows that the thought I had was a symptom of OCD, and that I had that symptom specifically because it is the worst thing my OCD could come up with. The Bible also says that God is just – He could not be just and also knowingly condemn someone for the symptom of their illness. Furthermore, the Bible says to test the spirits and see if they are from God, and says that the Holy Spirit is not a spirit of fear. Jesus says “do not be afraid,” and “do not let your hearts be troubled” and that Christians should trust Him, not their fear. This clearly sets OCD up against Jesus and God, OCD is not on God’s side. I believe that God’s only concern with this OCD thought is that it is harming me – He doesn’t see it as offensive to Himself.
Christian arguments against the thought (re. the devil). There is evidence from Biblical scholars that the devil is not meant to be read as a literal individual. Even if we did accept that he was a literal individual who could hear our thoughts, he would know that my thoughts were OCD. Furthermore, supposing we accept that hell is a place where the devil resides – in this case he is still under God’s rule, according to the Bible. He is not “in charge” of hell, according to the Bible. In this manner the power of the devil to harm me would be the same in hell as it is on earth. I am not afraid of him causing me additional harm on earth. This gets to the heart of the fear really – uncertainty and fear of the unknown (in this case death).
Arguments against the notion that I intended to “give the finger” to the Holy Spirit or the devil. This argument won’t work for everyone(!) but I have never “given the finger” to anyone in my life. I never use direct insults at people, even when I’m angry. I rarely use insults when I’m talking about someone I am angry with, even if they are not there. I may have been angry with OCD when I had this OCD thought, but I was not angry with the Holy Spirit or the devil. Even if I had been I wouldn’t have sworn at them. (As an example from UK politics – I was one of the students inspired by Nick Clegg to vote for the Lib Dems, then I watched him triple tuition fees after promising to scrap them. When I met him I told him this but I stayed civil! Like many of those students I haven’t voted for the Lib Dems again, but I digress.)

So after writing all three posts in this series I have done a bit of birthday planning. This kind of OCD thought won’t diminish much until I go against it, so I’ve tried to be brave.

Anatomy of an OCD thought: Part 2 – the practice

Click here to read Part 1.

Click here to read Part 3.

CONTENT WARNING: In this post I discuss the content of my religious OCD. If you have religious OCD, or other forms of OCD which involve magical thinking (e.g. “if I do x then y will happen”) please take care if reading on. OCD has been known to “take on” new symptoms when hearing about other people’s symptoms. (The post starts below the picture).

I’m now going to write about a specific OCD thought that is based on the OCD lies I described in Part 1. I hope that by writing it out I can help myself to see it for what it is, and show other people what OCD looks like in detail.

A couple of weeks ago I was on my way into town and I itched my eye with my middle finger. OCD told me that this meant I was giving the middle finger to the Holy Spirit or the devil. [It is frightening for me to write that.] OCD told me that I had to “correct” it. In order to correct it, what I needed to do was itch my eye with a different finger whilst in the same position on the road and whilst listening to the same part of the song that I was listening to when I originally itched my eye. OCD says that if I can do this successfully then I will ensure that I am not insulting the Holy Spirit or the devil.

I have tried to “correct” it, but haven’t managed to do so in a way that makes me feel it’s been properly corrected and “made safe”. I can’t keep trying to make it safe at the moment, a) because I am many miles away from the place I had the thought, b) because when it comes to “correcting” something OCD is never satisfied – anyone with OCD will know that however hard you try to do as OCD wants it will keep changing the goalposts. For example it will say I wasn’t quite in the right position, or the wrong part of the song was playing (I can’t actually remember the exact position or the exact part of the song that was playing, so OCD is bound to capitalise on that).

The way it is bothering me now is that I want to plan an event for my birthday. OCD is telling me that I can’t, because the eye-itching situation has not been adequately corrected. If I were to go ahead and plan the event I would need to re-do the planning once the eye-itching thing had been made safe. This is a good example of one of OCD’s tricks – in order to stop you moving on from a situation like this it will attach itself to a situation in the future, ensuring it stays in your mind.

Another trick OCD is using at the moment is making me doubt my intentions – it’s telling me that by itching my eye with my middle finger I was intending to insult the Holy Spirit and the devil. This gives OCD more power as it’s harder to dismiss as an intrusive thought if it tells me that it was actually me who was behind the thought. I will try to tackle this in Part 3.

Anatomy of an OCD thought: Part 1 – the theory

Click here to read Part 2.

Click here to read Part 3.

OCD’s “theory”

The idea that I have insulted the Holy Spirit or the devil are the most powerful thoughts that my OCD uses. They underpin almost every OCD thought I have and every compulsion I do. I’m planning on doing a later blog post about strategies I have found useful in combating these lies that OCD tells. For now I’m mostly going to describe what they mean to me in the context of my mental illness.

There are 2 verses in the Bible in which Jesus says all sins can be forgiven, but insulting the Holy Spirit cannot be forgiven. Scholars of the Bible suggest that these verses mean that if you reject God (i.e. reject God’s gift of His Spirit) then you can’t be forgiven because you are choosing not to accept His forgiveness. The verses are not referring to a specific event or to insulting language etc. I know this, but OCD still uses the verse to terrify me. The ultimate fear behind this, for me, is the idea that if I insult the Holy Spirit I will not be saved and will not go to heaven. I no longer believe that hell is a real place, but my OCD still keeps me afraid of going there. I’ve discussed in other blog posts how having OCD means you can know that something is incorrect yet still fear it.

The second thought that OCD uses, that I could insult the devil, is also ultimately linked to a fear of hell. The OCD rationale says that if I insult the devil and one day end up in hell then the devil will single me out for specifically harsh treatment. This rationale depends on cultural notions of the devil as being in charge of hell, an idea that came into fruition long after the Bible was written. This concept of the devil as a god of hell is not actually Biblical. Even if you take the view that hell is a place, there is nothing in the Bible to suggest that the devil is in control there. In fact many Christians believe that the devil is not a specific being, but a metaphorical concept which was used at the time the Bible was written to describe the conflicting nature of the human mind – sometimes we want to (and do) do things that are wrong because it feels good, for example. The irony here is not lost on me – it’s plausible that when the Bible refers to the devil and demons afflicting people this is a pre-scientific description of what we now understand as mental illness.

One of the reasons my OCD has settled on these thoughts is that they can’t be disproved in the way that my earlier OCD thoughts could. If OCD tells me that my mum will die if I don’t stand in a certain spot, I can ignore OCD, then check if my mum is still alive. There’s no way to check whether I have insulted the Holy Spirit or the devil, and there’s no way to check whether I have stopped myself from going to heaven when I die.

Another reason why these thoughts are so powerful is that as a Christian I believe that God knows my thoughts. OCD is a condition which is based on intrusive automatic thoughts. Recovering from OCD involves accepting that you can’t control your thoughts – “but what if,” my OCD says, “by letting these thoughts go by, I am insulting the Holy Spirit and ruining not just my life but my eternity?” This is terrifying, and gives you an idea of why religious OCD is so difficult to treat.

I also fear that the devil knows my thoughts, or listens to the things I say out loud in attempt to prevent me from getting totally stuck, such as “I am not insulting the Holy Spirit or the devil if I use my left foot”. Again these fears are not based on a thoughtful reading of the Bible, but are more based on myths created by writers such as Dante.

This post has outlined some of what lies behind my OCD thoughts. Read Part 2 to see a concrete example of what this looks like in practice.

Embarrassment and shame

There’s a bonus for reading to the end today – find out how my OCD convinced a drunk man that my car was a TARDIS…

I had a bad experience today. Even though I’ve said in other posts that I can hide my OCD pretty well, since it’s been severe it’s been harder to hide in public.

I had a meeting in a new building, and was on my way out. This involved a lot of doors and steps, which was very difficult for me OCD-wise. I tend to think something along the lines of “left, right is safe” before I go through a door or down steps, and then I follow whichever pattern I have said is safe. [I won’t go into what I mean by ‘safe’ in this post, you just need to know that it is a way to prevent my worst fears happening.] Sometimes I think “left, right is safe and right, left is also safe”, or other variations, to try and give myself more flexibility. These days (as OCD is bad) I often say these things out loud if I’m alone or with people very close to me; whether I say it or think it in public depends on whether or not people would hear me.

I was walking out of the building alongside the people who had been in the meeting, one of them was directing me (as I was new to the building). It was difficult to do all my OCD thoughts and keep them hidden at the same time, but I don’t think my colleagues noticed my slight pause at the start of some of the flights of stairs.

The part where I got stuck

When we went through one of the doors near the exit I felt like I hadn’t obeyed the thought I had made (I can’t fully remember but I may have thought “right, left” was safe but not managed to follow that properly in my stepping – thinking about this makes me a bit nervous now). I had to go back to correct it, but I couldn’t do so whilst my colleagues were there. So I waited in the communal area until they were out of view, then went back to the door I was worried about.

I tried to ‘make it safe’ by going through the door and thinking the correct combination, but it was difficult as I didn’t know if my hand on the door counted as a ‘left’ or ‘right’, or if it was only the foot that I stepped with that counted. I went back and forth through the door a few times, trying to make it safe. Occasionally people walked through the corridor and I tried to pretend I’d only gone one way.

Covering my OCD

A woman in a nearby office saw me and asked if I was looking for someone, so I meekly asked where the toilets were (I already knew where they were, but I couldn’t explain what I was doing to a stranger – ironic as I’m generally a painfully honest person, partly due to my OCD). I followed her to the toilets, where I went in and texted my partner, feeling disheartened at what had happened. I didn’t go back to the door again, partly because the woman in the office next to the door might think I was a security risk(!) and partly because I tried to use my cognitive reappraisal to show myself that I didn’t need to go back again to ‘correct’ the bad thought. Now, a few hours later, I kind of half believe that it’s just OCD and half think I should go and correct it the next time I happen to be in that building.

How it feels

These sorts of symptoms are quite common, in fact there used to be a support website for people with OCD called “Stuck in a doorway”. When my OCD thoughts bleed into the real world in this way I think of what Joe Wells said in his book (“Touch and Go Joe”, about his experiences with OCD) – how can you have confidence in yourself when you can’t even get through a door? (I’m writing that from memory, so don’t quote me!)

It’s demoralising when I can’t hide OCD away. It makes me feel ashamed and ‘less than’, because I can’t just live like other people do. I also feel a bit embarrassed, as well as sad that it has got this bad.

Generally, when this sort of thing happens, people don’t seem to realise OCD is the reason for my actions. Thinking about it, maybe I prefer it that they don’t know the real reason. I feel a little ashamed (there’s that shame again) to admit that – because I want greater awareness of mental illness in society, and because it suggests that I still have some self-stigma when it comes to my mental health. Or maybe it’s OCD in particular – I find it easier to tell people I have mental illness than to tell people I have OCD.

To end on a lighter note…

It’s surprising how odd you can be in public without people noticing. A while ago I carried the same heavy, large box from my house to my car and back again 16 times whilst a man stood outside waiting for a taxi. It’s amusing to guess what he might have thought – it was a big box and a small car, so it was impossible for it to have been different boxes every time. This rules out the only logical explanation, that I was packing the car with multiple boxes. Perhaps he thought my car was a TARDIS.

OCD and school

I thought today I’d write a few things about the ways in which OCD affected my time at school. If this blog gains traction it might be useful for teachers.

Early signs

One of my earliest memories is from when I was 4 or 5. I thought I had stared at my teacher. I knew that I shouldn’t stare at people, and as a result I got very upset and started crying (because I had done something wrong). I don’t believe this was fear of being told off, because obviously no one else noticed my staring, if anything the teacher was probably pleased to have attention from one of her pupils. For me it was more focused on the notion that I had done wrong, and I should not do wrong. This isn’t OCD in itself, but it could have been an early warning sign of OCD traits, such as inflated responsibility and rigid thinking.

Fear of copying and cheating

In high school I was very concerned about copying others. When I took exams I spent the whole time with my hand covering the side of my face so I couldn’t accidentally see anyone else’s answers. I wouldn’t let my parents help me with homework as I felt I should do it myself, otherwise it would be cheating. I would struggle for hours rather than accept help.

In my GCSE History exam I put my pen down a couple of moments after the teacher told us to stop writing. When I got my GCSE results they were very good (if I may say so myself!) but I wasn’t able to enjoy them because I felt that I’d cheated on the History exam. I went to speak to a history teacher and found that I was 14 marks past the grade boundary – this reassured me a little as it wouldn’t be possible to gain 14 marks in 2 seconds. But the overwhelming feeling I experienced when I received the best set of marks of my life (they remain my best relative marks to this day), was that it was undeserved and that the whole set of GCSE marks (from all subjects) was tainted because I’d cheated in History. Now I am proud of them and I know I didn’t cheat, though I couldn’t tell you how long it took for me to get to this view.

Another related way in which OCD affected my school work was in a piece I wrote for English. The options were to write a story or an autobiographical piece. I wanted to write a story, but some of my friends had chosen that option and I thought I would be copying if I did the same thing, so I wrote the autobiographical piece instead…

Moral fears and scrupulosity

This autobiographical piece ended up being a nightmare to write, because my OCD made me feel like I needed to write it as a moral example for my teacher (with hindsight this is somewhat comical). I suppose I was frightened of writing anything that might lead my teacher astray morally. This could be seen as an example of scrupulosity, a type of OCD which is focused on religious or moral obsessions. I ended up getting one of the worst marks I’d ever received.

OCD’s interaction with my future

Talking of bad marks, OCD really interfered with my A levels as well. I had an offer to study at one of the best universities in the UK, but I needed to get top grades to finalise the offer. I was desperately anxious during that time (for a range of additional reasons), and my OCD was a nightmare.

It is difficult to remember exactly what happened with this next example, but I think it was a mixture of things. Part of it was that I had spent so much time as a teenager OCD-checking things that I struggled to engage with the action of checking, as it caused me so much anxiety. I expect I also had bad thoughts about which words I could write without terrible things happening. And I wouldn’t allow anyone to help me with my work as that would be cheating. I vaguely remember trying to print the piece of work and being scared to even look at it as it was so important that it was a huge target for my OCD and I could barely cope with the anxiety of handling it. [Writing this 12 years later I’m actually proud of myself for working so hard in the face of almost total panic].

This culminated in me submitting work with an obvious mistake in the title, and I ended up getting a D. I desperately needed an A overall in order to take up the offer I had from university, and this was a big blow to that. Eventually I told my teacher about my OCD and she advised me to exercise. She had no idea how ill I was, which I suppose was partly because I had been hiding it somewhat, but also because she didn’t know about mental illness. Her strategy (as I experienced it) when I struggled was to put more and more pressure on, and my grades got worse. I was also spending so much time on this subject that I didn’t have as much time to devote to Maths, which was the A level that I was least naturally suited to.

On results day I was woken up by my heart beat. My place at the top university had been declined because my grades were ABB. I rung them up and asked if they had considered what I had told them about being mentally ill, and the woman said they had thought about it but they had ‘sticklers for grades’ who would complain if they let me in. Two days later my first boyfriend broke up with me because I didn’t get into the university like he had done.

A happy ending (for a change)

School interacted badly with my OCD, partly because the teachers didn’t recognise that anything was wrong, and partly because I was adamant that the teachers shouldn’t know about it (until the very end, when it was so obviously harming my work that I felt that telling them was the only option). I’m trying to remember why I was so resistant to the teachers (and my GP) knowing – it was probably a mixture of not wanting to accept how ill I was (and still hoping I could get better on my own), self-stigma, fear of being treated differently, and not wanting to accept that attaining academic perfection might not be in my reach anymore, given how bad my OCD was.

But to the happy ending… if I didn’t have OCD I might well have got over the line on the grades, and gone to one of the best universities in the UK. But I was still able to go to a good university, and I’m at a similar place career-wise than I would have been if I’d gone to the other university – maybe a couple of years behind, but that’s ok. Most importantly I met my partner at the university I did attend, so whilst OCD won the battle for my A levels, I ultimately ended up better off as a result.

The time I got better

I was 10 or 11 when I became unwell with OCD. From then on, OCD stayed with me in various guises, unrelenting. I first sought medical treatment when I was 17 (before that I’d resisted attempts to get medical help). I basically went to my GP and told her I had OCD. By that point I already knew all about OCD and how it affected me.

A quick overview of some of the times I didn’t get better…

I started antidepressants when I was 17, and although I’ve tried various kinds I haven’t seen much of an improvement from any of them. I remember when I was first prescribed medicine I was so hopeful that I would get some relief, but I didn’t. Having said that, more than a decade later I’m still on a high dose of antidepressants – when I tried to come off them a few years ago my OCD got even worse.

In terms of psychotherapy I’ve seen lots of different practitioners over the years. With most therapists my OCD remained mostly unchanged, with one therapist (a psychiatrist) it got worse, and in two cases it improved. The first time it improved was when I had regular sessions with a clinical psychologist who applied cognitive behavioural therapy (CBT) techniques in a dynamic way which took account of my individual symptoms. I made some great progress, genuinely beginning to get on top of my OCD for the first time. The sessions took place over the summer, in between academic years at university. I had been in a sort-of relationship with someone from university, who didn’t like to be seen in public with me, for about 10 months. When I went back to university, and back to the stress and uncertainty of that situation, all the progress I had made over the summer just dissipated. It felt like trying to hold back water. Weeks/months of consistent hard work disappeared within 2 weeks of being back at university.

One of the most cruel things about OCD is that to get better you have to be consistent in your fight against it, which takes a lot of energy and is very frightening, but to get worse all you need to do is have a brief ‘off’ period. But don’t despair, you can get better! Which leads me on to…

The time I got better

The second time I got better my progress did stick. There were a number of factors which I think contributed to me getting well at that time.

My life circumstances were more settled and stable than they had been for a long time (e.g. I was now in a stable, beneficial relationship).
My therapist had a thorough understanding of OCD, the techniques that could be used to treat it and how to apply these techniques in an appropriate manner.
My therapist happened to be a Christian, which meant she could easily tell the difference between my religious OCD thoughts (which were focused on Christianity) and what was actually part of the religion itself.
The first ‘half’ of the treatment was focused on cognitive reappraisal (with exposure coming later on). I believe this was fundamental to my success – some people’s OCD responds well to exposure on its own, but the reason I was able to capitalise on the exposure exercises this time is that I had spent a long time strengthening my ability to reappraise the OCD thoughts. This helped me to see them for what they were, at least to some extent, and exposure then helped me to consolidate this.
(I changed back onto Sertraline after being on Venlafaxine. This point is in brackets as I didn’t feel an improvement from this in itself (other than the removal of Venlafaxine’s more intense side effects). But it’s possible it supported the CBT I was working on – Sertraline is a recommended medicine for OCD).

I was able to become clinically well (below the clinical threshold for OCD), and to remain well for about 1 to 2 years. I’d guess it took me about 6 – 9 months of weekly or fortnightly CBT to get there. Everyone who knew me well, including me, was amazed. I had been very ill since I was a child, and one of the things you may hear about OCD is that it has to be managed, not cured. Perhaps I just have a different concept of what ‘managed’ and ‘cured’ are, but for me, having the occasional slightly intrusive thought which I was able to bat away, a few times per day, felt like being cured.

Being well felt like the world was colourful. I realised just how much I had been dealing with; I remember thinking “if this is what life is like for other people it’s no wonder I’ve been struggling so much with life.” The first Christmas I was well I joined in much more with family activities than I had previously – I had more mental space to engage with others as I wasn’t also dealing with OCD’s constant ramblings. My anxiety level was lower as I didn’t have my worst fears in my thoughts all the time. That helped me to engage more as well.

As you will have realised from the rest of this blog I became ill again. However it took a couple of years and a lot of intense interpersonal and work stress to bring it back. A few months after I had finished CBT my grandma passed away – I thought OCD would use this time of difficult emotions to stage its comeback, but it failed to do that – I kept it at bay. I wish I hadn’t got ill again, but I am optimistic that I can get well again, and stay well for longer this time. After all, this time I know it is possible, because I’ve done it before.