Walking the dog with OCD

Proceed with caution if you have religious OCD, especially if it’s based on Christianity – here I talk about some of my religious thoughts without going into detail on why they’re wrong (though be assured they are wrong, as is every OCD thought).

Just got back from a dog walk. I fought hard with OCD on this walk – specifically, by allowing my feet to face white marks when I was walking, even if there was a beat at the same moment in the song I was listening to. This post is about the point at which I struggled most during the walk, due to a specific thought which took hold more than the others did.

The thought

There was a word in a song I was listening to that sounded a bit like “fool” (I don’t think it was “fool”, it might have even been a French word). My foot was pointing at something white, and in OCD parlance that means using that word to describe the Holy Spirit (white = Holy Spirit). OCD tells me that this in turn means I will go to hell, due to insulting the Holy Spirit. This is bolstered by a Bible verse in which Jesus says if you call your brother a fool you’re in danger of the fires of hell – so I’m quite nervous about the word “fool” in general, even though I’ve heard other Christians use it without concern, and even though I don’t really believe in hell. Interestingly it takes a whole paragraph (with additional links) to explain this thought, but in my head it’s pretty much instantaneous – all those connections are just something I “know” less than a second after it’s happened.

Whether to neutralise the thought

OCD said I had to neutralise what I’d done by winding the music back and walking back to the spot in order to “take it back” or “take it back into myself” by making some kind of mental movement towards myself whilst my foot was pointing at the white mark and the word came up in the song. Alternatively I could neutralise it by thinking or saying “no” or “not” whilst pointing at the white spot with my foot at the moment the word came up in the song. This would, according to OCD, “undo” what I’d done wrong. (Incidentally, beware of OCD claiming that your compulsion can make something ok – OCD will never be satisfied that you’ve done it correctly enough for it to be truly safe).

Choosing not to neutralise it

I didn’t want to neutralise it as I’m trying to do exposure when I walk. So I spent about 3 to 5 minutes stood still trying to work out what I should do (my dog meanwhile had a lovely run in and out of the woods). Then (and now) I don’t have a great deal of access to the reality that this is preposterous and makes no sense – it feels quite real. Nevertheless I used the arguments that a) God knows it’s OCD and doesn’t want me to obey it, b) my brain can’t use safety signals properly, so it won’t be possible for me to feel that it’s ok; I have to choose to believe it is safe even though it feels threatening. I didn’t go back in the end, though I’m still feeling anxious about that decision about half an hour later. My Fitbit reckons I was doing cardio exercise during this walk (a leisurely walk in the sun + OCD = 143 beats per min – I’m not especially fit but I’m young and physically healthy, so it shouldn’t be this high).

We walked through a meadow a bit like this

Yesterday, when I walked the dog with my mum and sister through a meadow, my sister commented on how nice it was and that we were living our best lives. I brought the tone down a bit by adding that I was in the process of trying to prevent my eternal suffering. It reminded me of a joke John Robins made, that when he goes on holiday he can’t relax because he (i.e. the problem) is still there. OCD is there 24/7, whether I’m in a relaxing situation like having a massage, whether I’m concentrating on something or doing my favourite activity. It did stop for 20 minutes when I gave an important talk recently as all my mental resources were focused on the talk. OCD also shut up for the majority of episode 5 of Game of Thrones season 8, as it’s my favourite programme and a lot was happening. OCD was there as usual in episodes 4 and 6 though.

Today’s exposure

My posts have been getting a bit long so I’ll try and keep this short! My exposure therapy for this week is to walk to places without listening to/obeying what OCD says about how I should walk.

I’ve written previously about how OCD makes it hard to walk. Typically, I have to think about almost every step, and place my foot in a manner that is “safe”. This involves making a decision about each step based on the marks and objects (e.g. grids) on the pavement. Marks become particularly important if they are white, red, or comparable to white or red, e.g. a brown grid counts as red, an old chewing gum stain counts as white. This makes it tiring to walk because I’m doing so much in my head, and can end up with me walking back to walk past a spot again if I haven’t done it “safely” the first time.

Today and yesterday I deliberately tried not to adjust my walking according to OCD, as this is what my therapist and I decided I would do. This is a form of exposure therapy. It did raise my anxiety quite a lot, and I didn’t really experience the pattern of high anxiety followed by decreasing anxiety, which is what you would expect and aim for during exposure. This might have been because of the different levels of distraction I had at different times. The anxiety started high and fluctuated across the course of the walk – when I saw a dog and texted my partner about it, my anxiety went down a bit. I like to listen to music when walking but it does interact with my OCD. Generally, my OCD makes me concerned about where I step/what my foot is pointing at/what colour I’m looking at on certain beats in the music. I also have to be very careful how I’m standing/what I’m looking at when the artist says swear words or insults.

At one point I thought “I’m just walking, like people do!” which was a nice moment. I haven’t been able to just walk like other people do for a few years now. I’m cautiously optimistic that this is the start of getting back to being able to walk without OCD wittering on in the background. My therapist emphasised that I should reward myself for effort, not achievement, so I’m going to have some baklava and a sit down later on.

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.