In this week’s episode, our podcast hosts Lauren Rosen, LMFT, and Kelley Franke, LMFT, have a conversation about the ins and outs of overt compulsions.
Compulsions land in two categories: overt (physical) or covert (mental).
Covert compulsions and the ones that are invisible to the eye and exist within the sufferer’s mind. Overt compulsions are those behaviors that we can see.
With that in mind, let’s dive into this week’s episode…
Compulsions are the bad guys
Kelley: A few episodes back we went over mental compulsions. So I think it’s worth going over these very overt ones; the ones that are observable and that people can see versus the ones in your noggin.
Lauren: Some of them live up here, in your head. Some of them live out here, but they’re all compulsions.
Kelley: Yes. And just as a quick reminder, compulsions are the bad guys. So if we can remove the compulsions, we’re in really good business.
What are compulsions?
Lauren: …compulsions are done to eradicate uncertainty, anxiety, and OCD. So let’s take an example. You have an obsession pop in your mind that somebody might break into your home in the middle of the night? Ooh, scary. Oh, yes, it is. Scary. Obsessions are always scary. That’s kind of their deal. And so you have this obsession pop into your head and you begin to feel those levels of anxiety rise. You’re not sure what you should do. So you might be tempted to go and check the door again, right? You might want to check the lock on the door or perhaps the lock on the windows or to make sure the windows are closed ‘for certain’.
Kelley: …or redo them a few times. Or ask for reassurance. You might ask them if they think the door is locked properly, or even have them do it for you to hand over the responsibility of any negative consequences.
Lauren: …Sometimes people have a core fear that they’re going to be responsible for other people’s harm and sometimes it’s the fear that harm will come to you. It’s different for everyone but the behaviors look similar.
Locking the door. Re-locking the door. Staring at the lock. Checking a certain number of times, etc.
Different types of overt compulsions
Kelley: …Counting. That’s a big one. It can be either in your head or it can be out loud. Repeating something over and over. Looking at things in a certain direction, having to look from left to right, for example.
Lauren: There’s also tapping. You might have an intrusive thought that your mother might die for example, and then tap to find relief from that thought. I’ve worked with people who tap the walls a certain amount of times. It has to be even or odd. Sometimes counting can be a mental compulsion but it can also be a physical one.
Kelley: The compulsions are so endless. There’s washing which is not always related to contamination, folks. So keep that in mind.
Lauren: I was going to say, it’s not necessarily substance contamination, but oftentimes will fall into a category of emotional contamination or needing things just right. Even within religious scrupulosity, right? If you have sex and there’s fear about that making you impure somehow then you might feel the urge to clean yourself afterward. There are lots of ways that bathing and washing can come up.
With washing and cleaning ourselves, sometimes it can just be about duration. That being said, sometimes there are pretty extensive rituals that go with that process. So a person might have to wash their hands and then wash underneath their nails, and so on and so forth. The ritual itself can be extensive.
Kelley: Or it can be that we don’t wash all day and then we do this massive wash at the end of the day to clear the space.
Lauren: Before getting into bed, for instance, right? That’s oftentimes a safe space for people so they can be contaminated in other realms but not in this sacred space.
Lauren: You nodded toward observable reassurance seeking earlier and that can take so many different forms. Whether confessing something to your therapist (we see this a lot in our practices) to see if your therapist responds. If they don’t, then you’re in the clear!
There’s nothing wrong with telling your therapist about what’s going on in your life. It’s just when it becomes redundant and repetitive, it’s something that we’re on the lookout for.
Kelley: Reassurance isn’t compulsive until it’s compulsive.
Lauren: This essentially means repetitive and excessive. That could look like blatantly saying, what do you think?
Kelley: Sometimes it’s so sneaky that even a therapist can sometimes miss that it was reassurance-seeking behavior when asked so nonchalantly.
Lauren:… with reassurance seeking, it’s an anxious response and if your loved ones don’t have information about how to navigate OC effectively, they might unknowingly be feeding into the cycle. That being said, while people can get support around this by informing their loved ones and asking them not to enable reassurance-seeking or indulging their reassurance-seeking questions, a lot of it has to be on the person. Right? A lot of it has to be on you. You can say, you know what, don’t answer that question.
Avoidance as a compulsion
Kelley: I guess that kind of jumps off to the avoidance piece. You might get stuck in a cycle of needing to check to do the act yourself, or you might avoid it completely. You might ask someone else to check. You might just avoid locking the door at all, for example.
Lauren: You might avoid driving because you’re afraid that when you get in the car, you’re gonna have thoughts that you ran someone over and get stuck in a loop of checking and checking. So you decide to just stop driving full stop.
Lots and lots and lots of creative ways to avoid that are potentially the most blatant ways in which one’s life gets limited by this disorder.
There never seems to be an in-between either. When we diagnose anxiety disorders, lots and lots of overlap with OCD. We have to diagnose it as either care-seeking or care-avoidance.
So it’s either, calling your doctor constantly to get yourself checked or… It’s avoiding the doctor completely.
Kelley: If we’re thinking about health-related stuff, there are visually checking your body for things and scanning things. It could be going to get checked for an STD or HIV – that’s a big one for OCD. Huge one.
Avoiding anything that’s red.
Lauren: Yes, like blood. Someone with contamination concerns might avoid colors they associate with the disgust factor. Like avoiding anything that’s brown because that could be fecal matter.
And to your point earlier, you might check in the mirror to see if your eyes are yellow.
There are all sorts of ways in which we can observe somebody mid compulsion, although, interestingly enough, it may not tell the whole story. You may see somebody tapping but you may not hear that they’re reciting a prayer in their mind at the same time over and over again.
How to navigate the fear of someone breaking into your home (an example)
Kelley: Really broadly, we would want to bring up the anxiety. So you could write a story surrounding your obsession and imagine it coming true and everything going wrong. We want to induce that anxiety. For example, my OCD therapist told me this is OCD and told me not to check the locks on the door so I didn’t and because I didn’t, a person broke in tonight.
The response prevention element of ERP therapy would be when you’re reading this story, you’re not mentally convulsing. You’re sitting with the uncomfortable feeling and you’re not going to do any compulsions following that. If there’s a great big urge to do a ton of convulsions to alleviate that anxiety and you engage in those, then we’ve gone off the map.
Lauren: Even just locking the door itself is an exposure. Right?
You might always avoid locking the door, that may be the compulsion piece. But maybe you become the designated door-locker. Maybe we look at how many times you want to check the door is locked, this is where the response prevention piece comes in. So we might begin to limit the number of times you’re allowed to give yourself to check.
It’s all down to people’s willingness. We start where people are willing to start. It’s a matter of slowly chipping away at the compulsions because they’re the things that are impacting your life. They’re the bad guys, as Kelley was saying earlier.
You can also do an imaginal exposure and a real-life exposure at the same time. It’s a little more advanced but you could go and actually go to lock a single lock on your door whilst at the same time listening to the story in your mind about how you’ve not really locked it and that someone is going to break in. And you’re accepting and tolerating the feelings that are coming up, instead of trying to resolve the uncertainty about whether or not you actually did lock that door.